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[  section  showing  the  relation  of  the  viscera  in  their  normal  positions  (Dickinson). 
(For  details  see  Fig.  22,  p.  &2.) 


THE  AMERICAN 

TEXT-BOOK    OF 

OBSTETRICS 

FOR     PRACTITIONERS     AND     STUDENTS 

BY 
James  C.  Cameron,  M.D.,  Edward  P.  Davis,  M.D. 
Robert  L.  Dickinson,  M.D.,  Henry  J.  Garrigues, 
M.D.,      Barton    Cooke    Hirst,    M.D.,      Charles 
Jewett,  M.D.,  Howard  A.  Kelly,  M.D.,  Richard  C. 

NORRIS,  M.D.,   CHAUNCEY   D.  PALMER,  M.D.,  GEORGE 

A.  Piersol,  M.D.,  Edward  Reynolds,  M.D.,  Henry 
Schwarz,  M.D.,  J.  Clarence  Webster,  M.D. 

Richard  C.  Norris,  M.D.,  Editor 

Robert  L.  Dickinson,  M.D.,  art  Editor 

WITH  NEARLY  900   ILLUSTRATIONS 


Second  lEDition,  IRevisefc 


Vol.  I. 


W.    B.   SAUNDERS  &   COMPANY 

philadelphia  ___„  london 

925,  walnut  Street  9,  Henrietta  St.,  Strand 


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Copyrighted  March,  1895,  by  W.  B.  Saunders. 


Reprinted  January,  1896,  Oetotjer,  1896,  and  August,  1900. 


Copyright,  1902,  by  W.  B.  Saunders  &  Company. 


Registered  at  Stationers'  Hall,  London,  England. 


PREFACE  TO  THE  SECOND  EDITION. 


Since  the  appearance  of  the  first  edition  of  this  work  many  impor- 
tant advances  have  been  made  in  the  science  and  art  of  obstetrics. 
The  results  of  bacteriologic  and  of  chemicobiologic  research  as  applied  to 
the  pathology  of  midwifery  ;  the  wider  range  of  surgery  in  treating  many 
of  the  complications  of  pregnancy,  labor,  and  the  puerperal  period — 
embrace  new  problems  in  obstetrics,  some  of  which  have  found  their  final 
place  in  obstetric  practice.  It  seems  proper,  therefore,  to  offer  to  the 
profession  a  thorough  revision  of  this  text-booh.  Some  of  the  chapters 
have  been  rewritten,  others  have  been  thoroughly  revised.  A  number 
of  the  illustrations  that  appeared  in  the  first  edition  have  been  replaced  by 
others  of  greater  artistic  excellence,  and  several  additional  illustrations  have 
been  added. 

It  will  be  noticed  that  Dr.  J.  Clarence  Webster  has  been  added  to  the 
list  of  contributors  ;  while  it  is  with  deep  regret  that  the  editor  recalls  the 
death  of  Doctors  Theophilus  Parvin,  James  H.  Etheridge,  and  Charles 
Warrington  Earle.  The  chapters  by  Dr.  Etheridge  have  been  rewritten  by 
Dr.  Webster ;  those  by  Doctors  Parvin  and  Earle  have  been  partially  re- 
written and  revised  by  the  editor. 

By  reason  of  the  extensive  additions  to  the  text,  and  to  facilitate  ease  in 
handling  the  work,  it  has  been  deemed  advisable  to  present  the  new  edition 
in  two  volumes. 

RICHARD  C.   NORRIS.       . 
ROBT.  L.   DICKINSON. 


PREFACE. 


advances  in  the  science  and  art  of  obstetrics  have 
kept  pace  with  the  advances  which  have  characterized  all 
branches  of  medicine  and  surgery.  Although  our  stand- 
ard text-books  of  obstetrics  have  occasionally  been  revised, 
an  entirely  new  text-book  containing  the  writings  of  more 
than  one  individual  has  not  appeared  during  the  last 
decade.  The  American  Text-Book  of  Obstetrics  owes  its  existence  to 
the  fact  that  it  seemed  practicable  to  produce  a  work  which  should  not 
only  embody  the  teachings  of  several  prominent  American  obstetricians, 
thus  reflecting  all  recent  progress  made  in  the  theory  and  practice  of 
obstetrics,  but  should  also  be  a  standard  teaching-work  for  students  and 
a  guide  for  practitioners ;  for  this  purpose  the  authors  selected  are  those 
possessing  experience  as  teachers  of  obstetrics  in  several  of  the  leading 
medical  schools  and  hospitals  of  America. 

The  especial  design  in  preparing  this  volume  was  to  make  clear  those 
departments  of  obstetrics  that  are  at  once  so  important  and  usually  so 
obscure  to  the  medical  student.  Therefore  the  obstetric  emergencies,  the 
mechanics  of  normal  and  abnormal  labor,  and  the  various  manipulations 
required  in  obstetric  surgery  are  all  described  in  great  detail,  the  text 
being  elucidated  with  numerous  illustrations  and  diagrams  which  will  mate- 
rially assist  the  student  to  grasp  the  complex  problems  of  operative  obstet- 
rics. The  diseases  of  the  fetus  and  of  the  new-born  infant  are  given  sepa- 
rate sections  of  the  volume,  this  subject  being  discussed  more  fully  than  is 
usual  in  obstetrical  works  in  the  English  language.  An  effort  has  been  made 
to  render  attractive  the  sections  upon  Anatomy  and  Embryology. 

While  the  various  authors  were  each  assigned  special  themes  for  discus- 
sion, nevertheless  an  attempt  has  been  made  so  to  correlate  the  subject- 
matter  as  to  preserve  throughout  the  text  a  logical  sequence  not  always 
found  in  composite  publications.  The  writing  of  the  subjects  assigned  to 
Dr.  Charles  Warrington  Earle  was  only  fairly  begun  when  his  untimely 
and  widely-lamented  death  occurred.  The  Editors  were  gratified  to  secure 
for  the  revision  and  completion  of  Dr.  Earle's  manuscript  one  of  his  asso- 
ciates, Dr.  M.  J.  Mergler.  The  table  of  Contents  indicates  the  authorship 
of  each  section — a  feature  which  doubtless  will  give  satisfaction. 

One  of  the  just  claims  of  this  text-book  to  originality  is  that  an  attempt 
has  been  made  to  carry  out  systematically  the  following  principles  in  its 
illustration  :  All  figures  to  be  drawn  to  scale ;  a  uniform  scale  to  be  adopted, 
usually  one-third  or  one-sixth  life  size ;  in  sagittal  sections  the  same  half 
always  to  be  shown  for  ease  of  comparison ;  full  labelling  to  be  made 
directly  on  the  drawing,  to  which  should  be  given  as  much   artistic   treat- 


8  PBEFA  CE. 

ment  as  would  be  compatible  with  clearness  and  with  teaching  quality. 
The  scale  of  the  cuts  in  most  previous  text-books,  and  the  choice  of  the 
sagittal  section — right  or  left — have  varied.  In  this  book  the  left  half  of 
the  section  has  preferably  been  chosen,  because  it  is  the  one  made  familiar  to 
practitioners  by  the  treatment  of  patients  in  the  latero-prone  posture. 

Each  borrowed  engraving  has  been  credited  to  its  source  in  all  cases 
where  it  could  be  traced.  When  alterations  have  not  been  extensive  these 
cuts  are  designated,  respectively,  as  "  redrawn  from  "  or  "  modified  from  " 
the  original.  When  such  corrections  and  additions  have  been  made  as  to 
constitute  practically  a  new  drawing,  the  origin  of  the  cut  is  rarely  indicated. 
AVhere  there  may  seem  to  be  strong  resemblance  to  older  work,  without 
credit,  it  will  be  found  that  new  photographs  or  sketches  are  the  basis  of 
the  new  illustration.  The  borrowed  cuts  have  all  been  redrawn,  excepting 
those  reproduced  from  the  old  copper-plates  of  Hunter  and  Smellie — a  stand- 
ard of  artistic  excellence  set  for  us  by  the  most  famous  engravers  of  England. 
France,  which  has  furnished  our  specialty  with  its  stock-cuts  for  decades, 
gives  the  "  American  Text-Book "  many  suggestions  through  the  work  of 
Farabeuf  and  Varnier.  To  Germany  obstetrics  owes  much  gratitude  for  that 
accuracy  in  topographical  anatomy  which  had  its  rise  in  the  beautifully  pic- 
tured sections  of  Braun,  Schroeder,  Waldeyer,  and  Zweifel ;  while  we  thank 
Scotland,  through  the  atlases  of  Hart,  Barbour,  and  Webster,  for  the  know- 
ledge of  the  structure  of  the  pelvic  floor. 

Some  of  the  finest  pathological  specimens  illustrated  in  this  text-book 
were  photographed  at  the  Army  Medical  Museum  at  Washington,  D.  C, 
through  the  painstaking  courtesy  of  Dr.  D.  S.  Lamb,  while  Dr.  Farquhar  Fer- 
guson gave  access  to  the  New  York  Hospital  Cabinet,  and  Professors  Piersol 
and  Hirst  each  brought  forward  some  of  their  most  striking  preparations. 

We  are  indebted  to  the  staff  of  artists,  Messrs.  Max  Colin,  W.  A.  C. 
Pape,  H.  C.  Lehmann,  F.  V.  Baker,#A.  B.  Doggett,  F.  Deck,  W.  H.  Richard- 
son, and  others,  by  whose  skill  and  years  of  patient  labor  art  has  been 
placed  at  the  service  of  scientific  illustration. 

Only  through  an  unprecedented  liberality  on  the  part  of  the  publisher  of 
a  medical  text-book  has  it  been  possible  thus  to  re-illustrate  an  entire  depart- 
ment of  medicine.  To  Mr.  W.  B.  Saunders,  for  his  unremitting  courtesy, 
patience,  and  generosity,  we  tender  our  thanks.  The  Editors  desire  to 
acknowledge  their  indebtedness  to  Mr.  John  Vansant  for  valuable  assist- 
ance in  conducting  the  mechanical  details  of  the  work  and  for  the  prep- 
aration of  the  Index. 

The  plan  of  this  text-book,  the  exposition  of  only  the  latest  ideas  in 
pathology,  the  especial  care  that  directions  for  treatment  shall  be  particular 
and  full,  the  avoidance  of  conflicting  statements,  and  the  wealth  of  illus- 
tration, are  qualities  which,  it  is  hoped,  will  make  this  work  an  efficient 
guide  to  those  who  study  or  who  practise  Obstetrics. 

RICHARD   C.    NORMS, 
ROBERT  L.   DICKINSON. 


CONTRIBUTORS. 


J.  CHALMERS  CAMERON,  M.  D.,  Montreal,  Canada. 

Professor  of  Obstetrics  and  of  Diseases  of  Infancy,  McGill  University ;  Consult- 
ing Physician  Montreal  General  Hospital ;  Physician  Accoucheur  to  the  Montreal 
Maternity,  etc. 

EDWARD  P.  DAVIS,  A.  M.,  M.  D.,  Philadelphia,  Pa. 

Professor  of  Obstetrics  in  the  Jefferson  Medical  College  ;  Professor  of  Obstetrics  and 
Diseases  of  Infancy  in  the  Philadelphia  Polyclinic;  Obstetrician  to  the  Jefferson  and 
Polyclinic  Hospitals ;  Obstetrician  and  Gynecologist  to  the  Philadelphia  Hospital,  etc. 

ROBERT  L.  DICKINSON,  M.  D.,  Brooklyn,  N.  Y. 

Assistant  Professor  of  Obstetrics  in,  and  Assistant  Obstetrician  to.  Long  Island  Col- 
lege Hospital ;  Surgeon  to  Brooklyn  Hospital. 

HENRY  J.  GARRIGUES,  A.  M.,  M.  D. ,  New  York,  N .  Y. 

Late  Professor  of  Obstetrics  in  the  New  York  Post-Graduate  School  and  Hospital ; 
late  Professor  of  Gynecology  and  Obstetrics  in  the  New  York  School  of  Clinical  Medi- 
cine; Consulting  Obstetric  Surgeon  to  the  New  York  Maternity  Hospital;  Consulting 
Physician  to  the  New  York  Mothers'  Home  and  Maternity  Hospital;  Gynecologist  to 
St.  Mark's  Hospital  and  to  the  German  Dispensary,  New  York  City. 

BARTON  COOKE  HIRST,  M.  D.,  Philadelphia,  Pa. 

Professor  of  Obstetrics,  University  of  Pennsylvania ;  Gynecologist  to  the  Howard 
Hospital,  the  Philadelphia  Hospital,  and  the  Orthopaedic  Hospital. 

CHARLES  JEWETT,  M.  D.,  Brooklyn,  N.  Y. 

Professor  of  Obstetrics  and  Gynecology,  Long  Island  College  Hospital ;  Obstetrician 
and  Gynecologist  to  the  Long  Island  College  Hospital ;  Consulting  Gynecologist  to  Bush- 
wick  Hospital;  Consulting  Obstetrician  to  Kings  County  Hospital;  Consulting  Surgeon 
to  St.  Christopher's  Hospital. 

HOWARD  A.  KELLY,  M.  D.,  Baltimore,  Md. 

Professor  of  Gynecology  in  the  Johns  Hopkins  University,  Baltimore ;  Gynecologist 
to  the  Johns  Hopkins  Hospital. 

RICHARD  C.  NORRIS,  A.  M.,  M.  D.,  Philadelphia,  Pa. 

Lecturer  on  Clinical  and  Operative  Obstetrics,  University  of  Pennsylvania ;  Obstet- 
rician in  Charge  of  the  Preston  Retreat,  Philadelphia ;  Visiting  Obstetrician  to  the 
Philadelphia  Hospital ;  Consulting  Obstetrician  and  Gynecologist  to  the  South-eastern 
Dispensary  and  Hospital  for  Women  and  Children;  Gynecologist  to  the  Methodist  Epis- 
copal Hospital,  etc. 

CHAUNCEY  D.  PALMER,  M.  D.,  Cincinnati,  Ohio. 

Professor  of  Gynecology  and  Clinical  Gynecology  in  the  Medical  College  of  Ohio ; 
Consulting  Clinician  in  Obstetrics  and  Gynecology  to  the  Cincinnati  Hospital  ;  Consulting 
Gynecologist  to  the  German  Protestant  and  Presbyterian  Hospitals  in  Cincinnati,  etc. 


10  CONTRIBUTORS. 

GEORGE  A.  PIERSOL,  M.  D.,  Philadelphia,  Pa. 

Professor  of  Anatomy  in  the  University  of  Pennsylvania. 

EDWARD  REYNOLDS,  M.  D.,  Boston,  Mass. 

Visiting  Surgeon,  Free  Hospital  for  Women  ;  formerly  Senior  Physician  to  Out- 
patients in  Boston  Lying-in  Hospital ;  Instructor  in  Obstetrics,  Harvard  University. 

HENRY  SCHWARZ,  M.  D.,  St.  Louis,  Mo. 

Professor  of  Obstetrics  in  the  Medical  Department  of  Washington  University,  St. 
Louis,  Mo.  ;  Obstetrician  to  the  Jewish  Hospital ;  Director  of  the  St.  Louis  Free  Mid- 
wifery Dispensary ;  Consulting  Gynecologist  to  the  St.  Louis  City  and  Female  Hos- 
pitals, etc. 

J.  CLARENCE  WEBSTER,  B.  A.,  M.  D.,  F.  R.  C.  P.  E.,  F.  R.  S.  E., 

Chicago,  III. 

Professor  of  Obstetrics  and  Gynecology,  Rush  Medical  College,  affiliated  with  the 
University  of  Chicago;  Obstetrician  and  Gynecologist  to  the  Presbyterian  Hospital; 
Medical  Director,  Chicago  Lying-in  Hospital  and  Dispensary. 


CONTENTS  OF  VOLUME  I. 


I.  THE  GENERATIVE  ORGANS. 

PAGE 

I.  Anatomy  of  the  Pelvis  (Piersol) 17 

II.  Anatomy  of  the  Female  Generative  Organs  (Piersol)       36 

III.  Physiology  of  the  Female  Generative  Organs  (Piersol)      70 

II.  PREGNANCY. 

I.  Physiology  of  Pregnancy 74 

1.  Development  of  the  Embryo  and  Fetus  (Piersol) 74 

2.  Physiology  of  the  Fetus  (Piersol) 137 

3.  Multiple  Conceptions  (Piersol)   .   ; 143 

4.  Changes    in    the  Maternal  Organism    induced  by  Pregnancy 

(Piersol  and  Palmer*)  .    ; 147 

II.  Diagnosis  of  Pregnancy 161 

1.  Symptoms  and  Signs  of  Pregnancy  (Palmer) 161 

2.  Duration  of  Pregnancy  (Palmer  and  Piersol) 179 

3.  Prolongation  of  Pregnancy  (Palmer) 181 

HI.  Hygiene  and  Management  of  Pregnancy  (Palmer)  .  .   .  183 

IV.  Pathology  of  Pregnancy 188 

1.  Pathological  Conditions  of  the  Uterus  and  Appendages  (Davis)  .  188 

2.  The  Urinary  Organs  during  Pregnancy  (Davis) 220 

3.  Acute  Infections  during  Pregnancy  (Davis)     ...  282 

4.  Accidents  and  Surgical  Operations  during  Pregnancy  (Davis)      .  293 

5.  Diseases  of  the  Ovum  (Webster) 300 

6.  Premature  Expulsion  of  the  Uterine  Contents  (Webster)  .    .   .    .  312 

7.  Extra-uterine  Pregnancy  (Kelly) 324 

8.  Diseases  of  the  Fetus  in  Utero  (Norris) 346 

*  "General  Changes"   (pp.  154-160)  contributed  b_v  Dr.  Palmer. 


12  CONTEXTS. 

III.  LABOR. 


PAGE 


I.  Physiology  of  Labor 368 

1.  Phenomena  of  Normal  Labor  (Dickinson) 371 

2.  Clinical  Course  of  Labor  (Dickinson) 383 

II.  Conduct  of  Normal  Labor 391 

1.  Antisepsis  (Jewett) 391 

2.  Management  of  Normal  Labor  (Jewett) 398 

Obstetrical  Examination 399 

1.  Diagnosis  of  Fetal  Presentation  and  Position 400 

2.  External  Measurement  of  the  Pelvis 407 

3.  Vaginal  Examination Si 408 

4.  Anesthesia 412 

Examination  during  Labor 415 

Management  of  the  First  Stage 417 

Management  of  the  Second  Stage 418 

Management  of  the  Third  Stage 426 

m.  Mechanism  of  Labor 434 

1.  Classification  of  Labor  (Reynolds) 436 

2.  The  Fetus  (Reynolds) 451 

3.  Diagnosis,  Frequency,  and  Prognosis  of  the  Several  Varieties  of 

Labor  (Reynolds) 457 

1.  Vertex  Presentations   (Reynolds) 467 

1     Mechanism  of  the  First  Stage  of  Labor 473 

x5.  Mechanism  of  the  Secpnd  Stage  of  Labor 480 

C.  Mechanism  and  Management  of  the  Third  Stage  of  Labor  .    490 

D.  Mechanism  and  Management  of  Posterior  Positions  of  Ver- 

tex Presentations 492 

2.  Face  Presentations  (Reynolds) 508 

Mechanism  and  Management  .    .       510 

3.  Brow  Presentations  (Reynolds) 516 

Mecha        »  and  Management 516 

4.  Pelvic  Presentations  (Reynolds)     520 

Mechanism  and  Management 520 

5.  Footling  Presentations  (Reynolds) 537 

Mechanism  and  Management 537 

6.  Transverse  Presentations  (Reynolds) 537 

Mechanism  and  Management 53S 

7.  Prolapsed  Extremities  (Reynolds) 542 


CONTENTS.  13 


CONTENTS  OF  VOLUME  II. 


IV.  Dystocia. 
IV.  THE   PUERPERIUM. 

I.  Physiology  of  the  Puerperium. 
II.  Diagnosis  of  the  Puerperal  State. 

III.  Management  of  the  Puerperium. 

IV.  Pathology  of  the  Puerperium. 

V.  THE   NEW  B<  EX    INFANT. 

I.  Physioj    g1    of  the  New-born  Infant. 
II.  Pathology  of  the  New-born  Infant. 

VI.  OBSTETRIC    SURGERY. 

I.  Instrumental  Operations. 
II.  Manual  Operations. 
III.  Celiotomy  for  Sepsis  in  the  Child-bearing  Period. 


AN 


AMERICAN    TEXT-BOOK 


OBSTETRICS. 


AN  AMERICAN 


TEXT-BOOK  OF  OBSTETRICS. 


I.  THE  GENERATIVE  ORGANS. 


I.  Anatomy  of  the  Pelvis. 
Four  bones — the  two  ossa  innominata,  the  sacrum,  and  the  coccyx — take 
part  in  the  formation  of  the  pelvis ;  each  of  these,  in  turn,  is  composed  of  a 
number  of  segments  which  in  early  life  are  distinct  and  united  by  intervening 
cartilage.  The  pieces  comprising  the  innominate  bone — the  ilium,  the  pubis, 
and  the  ischium — earliest  unite,  although  the  union  of  the  several  portions  of 
the  acetabulum  is  not  complete  until  from  the  eighteenth  to  the  twentieth  year. 
The  sacral  and  the  coccygeal  segments  fuse  still  later,  those  of  the  coccyx  re- 


Fig.  1.— Female  pelvis  (one-third  natural  size). 

maining  movable  until  middle  life,  while  the  attachment  of  this  bone  with  the 
sacrum  occurs  late  in  life,  During  the  usual  period  of  childbearing,  therefore, 
the  segments  composing  the  posterior  boundary  of  the  pelvis  are  ununited,  and, 
in  the  lower  or  coccygeal  part  of  the  wall,  are  capable  of  yielding  to  the  demands 
of  parturition  for  increased  antero-posterior  or  conjugate  pelvic  diameters. 
The  pelvis  viewed  in  its  entirety  presents  an  inverted  truncated  cone  (Fig.  1), 


18  AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 

slightly  compressed  from  before  backward,  whose  base  is  directed  upward  and 
forward,  and  whose  smaller  end  looks  downward  and  backward.  The  sacrum 
and  the  coccyx  occupy  a  median  position  behind,  and  contribute  the  posterior 
wall,  the  innominate  bones  expanding  laterally  and  meeting  in  front  to  form 
the  pubic  arch  and  symphysis. 

The  space  included  within  these  bony  walls  is  divided  into  two  parts  by  a 
plane  passing  through  the  middle  of  the  sacral  promontory  behind  and  the 
upper  border  of  the  symphysis  pubis  in  front.  The  portion  of  the  body- 
cavity  lying  below  this  plane  constitutes  the  true  pelvis;  the  portion  lying 
above  this  plane,  included  within  the  widely  expanded  iliac  bones,  the  verte- 
bral column,  and  the  abdominal  parietes,  constitutes  the  false  p>elvis  and  be- 
longs to  the  abdominal  cavity,  to  the  contents  of  which  it  affords  support  and 
protection. 

The  true  or  lesser  pelvis  is  a  short  curved  canal  whose  superior  strait,  or 
inlet,  is  marked  by  the  brim,  a  bony  ring  defined  by  the  anterior  border  of  the 
promontory  of  the  sacrum  behind,  the  ilio-pectineal  lines  laterally,  and  the 
posterior  margin  of  the  pubis  in  front.  The  plane  of  the  inferior  strait,  or 
outlet,  passes  through  the  tip  of  the  coccyx,  the  tubera  ischii,  and  the  lower 
border  of  the  symphysis  pubis.  In  addition  to  the  foregoing  planes  marking 
the  upper  and  lower  boundaries  of  the  true  pelvis,  two  others,  corresponding 
with  its  widest  and  most  contracted  parts,  are  recognized  with  advantage. 

The  plane  of  greatest  pjelvic  expansion  extends  from  the  union  between  the 
second  and  third  sacral  vertebra?  behind  to  the  middle  of  the  symphysis  pubis 
in  front,  its  lateral  boundaries  corresponding  on  either  side  with  the  mid-point 
of  the  inner  surface  of  the  acetabulum. 

The  plane  of  least  pelvic  diameter  lies  somewhat  lower,  being  defined  by 
lines  passing  through  the  saero-coccygeal  articulation,  the  ischial  spines,  and 
the  lower  third  of  the  symphysis  pubis:  this  plane,  marking  as  it  does  the 
point  of  greatest  permanent  constriction,  really  constitutes  the  pelvic  outlet  in 
an  obstetrical  sense  more  than  do  the  lower  and  more  yielding  confines  to 
which  the  term   is  usually  applied. 

The  superior  strait,  or  inlet,  of  the  true  pelvis  is  slightly  cordiform  in 
outline,  since  the  low-arched  posterior  border  of  its  generally  oval  figure  is 
encroached  upon  by  the  sacral  promontory,  the  indentation,  however,  being 
much  less  in  the  female  than  in   the  male  pelvis. 

The  dimensions  of  the  inlet  (PI.  2,  Fig.  1)  are  represented  by  the  antero-pos- 
terior  or  conjugate  diameter  of  11.5  centimeters  (4J  inches),  measured  from  the 
middle  of  the  promontory  of  the  sacrum  to  the  middle  of  the  upper  border  of 
the  symphysis  pubis,  and  the  transverse  diameter  of  13.5  centimeters  (5f 
inches),  determined  by  the  greatest  distance  between  the  ilio-pectineal  lines; 
since,  however,  the  pubic  portion  of  the  pelvic  brim  lies  slightly  in  advance  of 
the  posterior  surface  of  the  pmbis,  the  available  antero-posterior  diameter,  or 
obstetric  conjugate,  is  somewhat  less  than  the  anatomical  dimension,  measuring 
11  centimeters  (PI.  2,  Fig.  2).  Supplementary  to  these  measurements,  the  ob- 
lique diameters  of  12.75  centimeters  (5^  inches),  measured  from  the  intersection  of 


ANATOMY   OF  THE  PELVIS. 


Plate  1. 


The  relation  between  the  pelvis  and  the  pelvic  organs  and  the  surface  of  the  body :  p,  promontory  of  the 
sacrum ;  s,  symphysis  pubis  ;  F,  fundus  of  the  uterus ;  0,  the  ovary  embraced  by  the  Fallopian  tube ;  the  line 
of  the  psoas  muscle  indicated ;  E,  the  rectum. 


ANATOMY  OF  THE   PELVIS. 


Marristal 


Interspinal 


Ischial 

lutwosity  __  Transverse    \> 


c/"ac.ruTO— ' 


1.  Diameters  of  pelvis  at  brim,  with  transverse  iliac  diameters.    2.  Diameters  of  pelvic  outlet. 


ANATOMY   OF    THE    GENERATIVE    ORGANS. 


19 


the  sacroiliac  articulation  with  the  ilio-pectineal  line  to  the  pubic  spine  of  the 
opposite  side,  are  usually  noted.  The  measurements  of  the  plane  of  greatest 
expansion  include  an  antero-posterior  diameter  of  12.75  centimeters  (5J  inches) 
and  a  transverse  diameter  of  12.5  centimeters  (5  inches).  The  plane  of  least 
dimensions  possesses  an  antero-posterior  diameter  of  11  centimeters  (4|  inches), 
as  measured  between  the  end  of  the  sacrum  and  the  summit  of  the  pubic 
arch,  and  a  transverse  diameter  of  11  centimeters  (4|  inches),  taken  between 
the  inner  surface  of  the  ischial  bones  near  their  posterior  border;  the  distance 
separating  the  spinse  isehii  is  about  10.5  centimeters  (4^  inches). 

The  inferior  strait,  or  anatomical  outlet,  of  the  pelvis,  although  less  regular 
in  outline  than  the  inlet,  possesses  a  general  ovate  form,  the  smaller  end  of 
the  figure  being  directed  anteriorly,  while  its  larger  end  is  impressed  by  the 
prominence  of  the  coccyx;  in  addition  to  the  latter  point,  two  other  osseous  pro- 
jections, the  tubera  isehii,  aid  in  denning  the  boundaries  of  the  outlet.    Between 


Fig.  2. — Female  pelvis,  viewed  from  below,  with  ligaments  (one-third  natural  size) 


these  tuberosities  in  front  is  included  the  subpubic  arch,  bounded  by  the  pubic 
and  ischial  rami,  while  behind,  between  them  and  the  sacrum,  lie  the  deep  sacro- 
sciatic  notches,  which  are  bridged  over  and  converted  into  foramina  by  the 
greater  and  lesser  sacro-sciatic  ligaments  (Fig.  2). 

The  dimensions  of  the  plane  of  the  pelvic  outlet  (PI.  2,  Fig.  2)  include  the 
antero-posterior  diameter  of  9  centimeters  (3J  inches),  measured  from  the  tip 
of  the  coccyx  to  the  summit  of  the  pubic  arch,  and  the  transverse  diameter  of 
11  centimeters  (4-|  inches),  measured  between  the  middle  of  the  ischial  tuberosi- 
ties. It  must  be  remembered,  however,  that  while  the  antero-posterior  diame- 
ter under  ordinary  conditions  is  only  9  centimeters  (3J  inches),  the  mobilitv 
of  the  coccyx  is  usually  such  that  this  diameter,  or  obstetric  conjugate,  is 
increased  to  11  centimeters  during  parturition  (PI.  2,  Fig.  2). 

The  cavity  of  the  true  pelvis,  as  appears  from  the  foregoing,  is  an  irregular 
cylinder  of  somewhat  varying  diameter;  the  imaginary  pelvic  axis  is  produced 


20  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

by  uniting  the  central  points  of  the  antero-posterior  diameters  of  the  superior, 
the  inferior,  and  the  intermediate  planes  above  described.  The  pelvic  cavity 
is  enclosed  by  the  smooth  surfaces  presented  by  the  surrounding  bony  parts ; 
its  anterior  wall,  formed  by  the  symphysis  and  the  bodies  of  the  pubic  bones, 
is  ccmvex  and  shorter  than  the  posterior,  measuring  but  little  more  than  4 
centimeters  (about  1 J  inches)  in  depth  ;  its  posterior  wall,  including  the  con- 
cave anterior  surfaces  of  the  sacrum  and  the  coccyx,  is  much  longer,  extend- 
ing 11.5  centimeters  (about  4  J  inches)  from  the  sacral  promontory  to  the  end 
of  the  coccyx.  The  lateral  walls  correspond  with  the  broad  quadrilateral  sur- 
faces of  the  ischial  bodies,  and  present  an  intermediate  depth  of  9  centimeters 
(3^-  inches). 

The  position  of  the  pelvis,  evidently,  must  vary  with  the  changes  in  the 
posture  of  the  body.  In  the  erect  attitude  the  plane  of  the  inlet  of  the  true 
pelvis  is  well  elevated,  forming  with  the  horizontal  an  angle  of  about  55° 
(50°  to  60°),  the  inclination  being  generally  somewhat  greater  in  the  female ; 
the  plane  of  the  outlet  coincides  more  closely  with  the  horizontal,  subtending 
with  the  latter  an  angle  of  about  11°  (PI.  3,  Fig.  1).  In  the  erect  position  the 
planes  of  the  perpendiculars  let  fall  from  the  anterior  superior  iliac  spines  and 
from  the  symphysis  pubis  coincide;  the  base  of  the  sacrum  lies  about  9  centi- 
meters (3J  inches)  above  the  upper  border  of  the  symphysis,  the  tip  of  the  coc- 
cyx at  the  same  time  being  about  2  centimeters  (f  inch)  above  the  summit  of  the 
subpubic  arch.  The  axis  of  the  pelvic  inlet  is  directed  forward  and  upward, 
toward  the  umbilicus  ;  if  prolonged  downward,  it  strikes  the  tip  of  the  coccyx. 
The  axis  of  the  outlet,  naturally  downward  and  a  little  backward,  will  meet 
the  promontory  if  extended  upward.  The  plane  of  the  symphysis  forms  an 
angle  of  from  90°  to  100°  with  that  of  the  pelvic  brim. 

The  importance  of  obtaining  definite  information  concerning  the  dimensions 
of  the  pelvis,  but,  at  the  same  time,  the  impossibility  of  determining  many  of 
the  foregoing  measurements  on  the  "living  subject,  has  led  to  the  substitution 
of  external,  readily  accessible  measurements  which  bear  a  direct  and  constant 
relation  to  the  internal  diameters.  The  most  useful  of  these  external  meas- 
urements include — the  distance  between  the  anterior  superior  iliac  spines, 
26  centimeters  ;  the  distance  between  the  iliac  crests,  29  centimeters ;  the  dis- 
tance between  the  greater  trochanters,  31  centimeters  ;  the  distance  between 
the  spinous  process  of  the  last  lumbar  vertebra  and  the  upper  margin  of  the 
pubic  symphysis,  or  external  conjugate,  20J  centimeters  ;  the  distance  between 
the  posterior  superior  spinous  process  and  the  anterior  superior  spinous 
process  of  the  opposite  iliac  bone,  or  the  oblique  diameter,  22  centimeters ; 
the  distance  between  the  ischial  tuberosities,  11  centimeters.  These  external 
diameters,  which  are  readily  obtained  by  means  of  direct  measurements  by  the 
pelvimeter,  bear  sufficiently  constant  relation  to  the  internal  diameters  to  make 
them  of  much  practical  importance.  As  pointed  out  by  Klein,  however,  the 
antero-posterior  diameter  is  subject  to  considerable  normal  variation.  The  aver- 
age thickness  of  the  bony  walls  at  the  points  of  measurement  being  known,  the 
subtraction  of  this  amount  from  the  ascertained  external  diameter  evidently 


ANATOMY  OF  THE  PELVIS. 


1.  Sagittal  section  of  female  pelvis,  showing  anatomical  and  obstetrical  diameters.  2.  Diagram  of  the 
structures  composim.'  the  pelvic  Hour:  1,  pelvic  fascia,  which  at  white  line  splits  into  rectovesical  taseia 
(2)  and  obturator  fascia  (1),  a  thin  additional  sheet,  the  anal  fascia  iiii,  covering  the  inferior  surlace  of  the 
levator  ani  muscle;  ft,  fi,  the  superior  and  inferior  layers  of  the  triangular  ligament;  7,  S,  deep  and  super- 
ficial layers  of  the  perineal  fascia;  9,  skin. 


ANATOMY    OF    THE    GENERATIVE    ORGANS. 


2"J 


supplies  data  con: parable  with  the  recognized  average  of  the  internal  dimensions. 
Thus,  the  distance  between  the  lower  edge  of  the  spinous  process  of  the  last 
lumbar  vertebra  and  the  middle  of  the  upper  margin  of  the  symphvsis,  meas- 
ured by  the  pelvimeter,  is  20  centimeters ;  from  this  are  deducted  the  9  centi- 
meters which  represent  the  combined  average  thickness  of  the  vertebral  body 
and  the  pubic  symphysis,  the  remaining  11  centimeters  corresponding  closely 
with  the  conjugate  of  the  superior  strait  as  determined  by  direct  measurement. 
The  size  of  the  female  pelvis,  although  presenting  many  individual  varia- 
tions, is  not  unfavorably  influenced  by  stature,  since  short  women  often  possess 
pelves  of  more  than  average  breadth.  The  distinctive  characteristics  of  sex 
are  acquired  after  puberty,  although,  according  to  Fehling,  indications  of  these 
peculiarities  are  present  even  at  birth.  Some  asymmetry  of  the  pelvis,  as  of 
other  parts  of  the  body,  is  usually  to  be  detected. 


Fig.  3.— Male  pelvis  (slightly  less  than  one-third  natural  size). 

The  following  table  exhibits  the  average  dimensions  of  the  fully  developed 
female  pelvis,  the  measurements  being  taken  from  the  dried  pelvis  : 

Centimeters. 

Greatest  distance  between  crests  of  ilia 28 

Distance  between  anterior  superior  iliac  spines 25 

Distance  between  last  lumbar  spine  and  front  of  symphysis  pubis 20 

True  Pelvis. 
Antero-posterior  Diameter        Transverse  Diameter        Oblique  Diameter 
(Centimeters).  (Centimeters).  (Centimeters). 

Plane  of  pelvic  inlet    ....        .11.  13.5  12.5 

Plane  of  greatest  expansion   ....  12.75  12.50 

Plane  of  greatest  contraction     .    .    .  11.  11. 

Plane  of  pelvic  outlet 9.5    (increased  to  11.5  cm.    n.  H  5 

by  displacement  of  coccyx). 

^  The  distinguishing  characteristics  of  the  female  pelvis  (Fig.  1)  as  contrasted 
with  the  corresponding  portion  of  the  male  skeleton  (Fig.  3)  include  slighter 


22 


AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 


bones  with  less  marked  muscular  impressions  ;  less  height  of  the  entire  pelvis  ; 
greater  breadth  and  capacity  of  the  true  pelvis,  but,  owing  to  the  more  verti- 
cally placed  iliac  bones,  relatively  and  absolutely  less  expansion  of  the  false 
pelvis  than  in  the  male  (Thane).  Both  the  inlet  and  the  outlet  are  larger  in 
the  female,  the  outline  of  the  pelvic  brim  approaching  more  nearly  the  circular 
form,  owing  to  the  slighter  projection  of  the  sacral  promontory.  In  the  female 
pelvis  the  sacrum  is  broader  and  less  concave,  the  depth  of  the  symphysis  is 
less,  and  the  subpubic  arch  is  wider,  embracing  from  90°  to  100°  as  against 
70°  in  the  male. 

In  addition  to  individual  peculiarities,  the  influences  of  race  markedly 
impress  the  general  form  of  the  pelvis,  particularly  the  relation  of  the  antero- 
posterior to  the  transverse  diameter :  the  broad,  cordiform  outline  of  the 
Caucasian  female  pelvis  is  replaced  by  one  nearly  circular  among  the  native 
Australians ;  among  the  Bushman  and  Malay  women  the  usual  ratio  between 
the  conjugate  and  transverse  diameters  becomes  so  altered  that  the  outline  of 
the  pelvis  is  an  upright  oval,  the  antero-posterior  dimension  surpassing  the 
transverse. 

Articulations  of  the  Pelvis. — The  component  bones  of  the  pelvis  are 
united  with  one  another  by  four  articulations  (Fig.  4) :  one  in  front,  between 


Fig.  4.— Female  pelvis  (viewed  from  above)  with  ligaments  (one-third  natural  size). 


the  two  pubic  bones ;  two  behind,  between  the  iliac  bones  and  the  sacrum  ; 
and  one  between  the  sacrum  and  the  coccyx.  The  opposed  bony  surfaces  are 
closely  united  by  fibro-cartilaginous  plates  and  external  ligamentous  bands, 
and  admit  of  very  limited  motion  ;  these  articulations,  therefore,  are  usually 
classed  as  amphiarthroses  or  symphyses. 

The  pubic  articulation,  or  symphysis  pubis  (Figs.  5,  6),  is  formed  by  the 
approximation  of  the  two  oval  articular  facets  occupying  the  mesial  borders  of 
the  pubic  bones,  which  are  connected  by  the  interposed  fibrous  disk  and  thesur- 


ANATOMY   OF    THE    GENERATIVE    ORGANS. 


23 


rounding  external  ligaments.  The  slightly  convex  surfaces  are  covered  with 
plates  of  cartilage  which  fill  up  the  inequalities  of  the  bones,  the  opposed  sur- 
faces being  held  together  by  the  intervening  mass  of  fibrous  tissue  and  fibro-car- 


n ,  ^ 


Fig.  5.— Section  across  symphysis  pubis,  showing  interpubic  disk  (Lusk). 

tilage  constituting  the  interpubic  disk  (Fig.  5).  This  layer,  which  projects  ante- 
riorly and  posteriorly  beyond  the  adjacent  bony  margins,  is  thickest  in  front ;  the 
deficiency  of  the  intermediate  tissue  above  and  behind  sometimes  results  in  the 
formation  of  an  interspace  or  fissure.  The  fis- 
sure within  the  interpubic  disk  extends  usually 
about  half  the  length  of  the  cartilage,  and  is 
produced  during  life  by  the  absorption  of  the 
fibro-cartilage :  it  appears  after  the  seventh 
year,  and  is  of  larger  size  and  more  constant 
in  the  female.  While  undue  tension  exerted 
upon  the  joint  during  labor  may  jjredispose  to 
the  production  of  this  fissure,  the  latter  is 
not  a  sequence  necessarily  of  pregnancy,  as  is 
shown  by  its  existence  in  pelves  of  males  and 
of  virgins.  A  slight  separation  of  the  pubic 
symphysis  during  pregnancy  is  regarded  by 
many  as  probable;  this  tendency,  however,  is  reduced  to  a  minimum  through 
the  bracing  effected  by  the  decussating  fibres  of  the  oblique  muscles.  The 
external  ligaments  which  additionally  strengthen  this  articulation  are  the  ante- 
rior, the  posterior,  the  superior,  and  the  inferior. 

The  anterior  pubic  ligament,  of  considerable  thickness,  consists  of  several 
strata  of  interlacing  fibres,  the  deepest  of  which  passes  directly  across  between 
the  bones  in  front  of  the  interpubic  disk,  with  which  they  are  blended ;  the 
superficial  layers  include  oblique  interlacing  fibres  continued  from  the  tendons 
of  the  external  oblique  and  the  recti  muscles,  and  of  the  more  superficial 
adductors  of  the  thigh. 

The  posterior  pubic  ligament  consists  of  a  few  sparingly  distributed  fibres 
which  unite  the  bones  behind,  and  it  is  little  more  than  the  somewhat  thick- 
ened periosteum. 

The  superior  pubic  ligament  is  represented  by  a  meagre  bundle  of  fibres 
occupying  the  upper  surface  of  the  articulation. 


Fig.  6.— Frontal  section  through 
symphysis  pubis,  exposing  interpubic 
cleft  (Farabeuf). 


24 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


The  inferior  or  subpubic  ligament,  on  the  contrary,  is  thick  and  triangular 
in  form,  and  it  contributes  the  smooth  boundary  to  the  summit  of  the  sub- 
pubic arch.     Throughout  the  middle  of  its  span  the  ligament  is  closely  united 


Fig.  7.— Anterior  view  of  symphysis  pubis. 


with  the  interpubic  disk,  being  attached  at  the  sides  and  below  to  the  descend- 
ing pubic  rami  (Fig.  7). 

The  sacro-iliac  articulation  (Fig.  8)  lies  between  the  lateral  surfaces  of  the 
sacrum  and  the  ilium ;  the  rough  articular  surfaces  of  both  bones  are  covered 

by  thin  plates  of  cartilage,  that  on  the 

v    •..,'« 'Vfl".; 5*.:'  V  . 

.  sacrum  being  thickest.  With  the  ad- 
vance of  age  these  cartilages  often  be- 
come roughened  and  partially  separated 
by  spaces  containing  a  glairy  fluid. 
Not  infrequently  the  apposed  bones 
are  united  by  intervening  bundles  of 
fibrous  tissue,  these  bands  constituting 
the  interosseous  ligament.  The  prin- 
cipal bonds  of  union  are  the  anterior 
and  posterior  ligaments. 

The  anterior  sacro-iliac  ligament 
comprises  a  number  of  thin  irregular 
fibrous  bundles  stretching  between  the 
front  of  the  sacrum  and  the  adjacent 
border  of  the  iliac  bone.  Associated  with  the  upper  and  lower  margins  of 
this  ligament  are  thickened  bundles  of  fibrous  tissue  that  spread  over  the 
ilium  respectively  as  far  as  the  ilio-pectineal  line  and  the  posterior  iliac  spine  ; 


Fig.  8. — Section  through  the  left  sacro-iliac  articu- 
lation (Luschka). 


ANATOMY   OF   THE    GENERATIVE   ORGANS.  25 

these  bands  constitute  the  superior  and  the  inferior  sacro-iliac  ligaments  some- 
times described. 

The  posterior  sacro-iliac  ligament,  which  is  of  great  strength,  extends  be- 
tween the  back  of  the  sacrum  and  the  posterior  border  of  the  iliac  crest.  The 
general  direction  of  the  fibres  is  downward  and  inward  from  the  ilium  ;  some 
of  the  fasciculi,  however,  pass  almost  horizontally,  while  a  special  bundle 
extends  nearly  vertically  from  the  posterior  superior  iliac  spine  to  the  third 
and  fourth  sacral  segments,  and  forms  the  oblique  sacro-iliac  ligament. 

The  sacro-coccygeal  articulation  includes  the  oval  facet  at  the  end  of  the 
sacrum  and  the  base  of  the  coccyx,  and  it  corresponds  in  its  ligamentous  struct- 
ures with  the  intervertebral  joints,  to  which  series  it  belongs.  The  bones  are 
united  by  the  anterior,  the  posterior,  and  the  lateral  bands  as  well  as  by  the 
interposed  intervertebral  disk. 

The  anterior  sacro-coccygeal  ligament  is  the  continuation  of  the  anterior 
common  ligament  of  the  vertebras,  and  it  consists  of  a  few  irregular  bands  of 
fibrous  tissue  that  pass  from  the  anterior  surface  of  the  sacrum  to  that  of  the 
coccyx  to  blend  with  the  periosteum. 

The  posterior  sacro-coccygeal  ligament,  stronger  than  the  preceding,  is  the 
prolongation  of  the  posterior  common  ligament,  and  it  descends  from  its  attach- 
ment around  the  lower  orifice  of  the  sacral  canal,  the  lower  hind  wall  of  which 
it  largely  forms,  to  the  posterior  surface  of  the  coccyx. 

Additional  posterior  bands  descend  from  the  sacrum  to  the  coccyx  as  con- 
tinuations of  the  interspinous  ligaments  intimately  blended  with  the  aponeuro- 
sis of  the  erector  spinas ;  the  lateral  expansions  which  connect  the  cornua  of 


A. 

o 

-1  Jt-' 

Fig.  9. — Variation  in  sacral  curves  (Hirst) :  P,  promontory  of  sacrum ;  C,  coccyx. 

the  last  sacral  segment  to  the  coccygeal  cornua  constitute  the  supracornual  or 
lateral  ligaments.  The  intertransverse  ligament  is  represented  by  fibrous  bands 
which  pass  from  the  lower  lateral  angle  of  the  sacrum  to  the  transverse  pro- 
cess of  the  first  piece  of  the  coccyx. 

The  intervertebral  disk  is  a  rudimentary  member  of  the  series  of  fibro-car- 
tilaginous  plates  interposed  between  the  vertebras ;  a  distinct  cavity  sometimes 
exists  within  this  disk  (Cruveilhier),  especially  when  the  coccyx  is  freely 
movable ;  this  mobility  seems  increased  during  pregnanev. 


26  AMERICAN    TEXT-BOOK   OF    OBSTETRICS. 

The  coccygeal  segments  are  held  together  by  the  extensions  of  the  anterior 
and  posterior  ligaments  and  by  the  rudimentary  intervertebral  disks  which  lie 
between.  The  individual  pieces  remain  distinct  in  the  female  during  early 
adolescence,  but  become  united  by  the  close  of  the  childbearing  period ;  in 
later  life  ossification  between  the  sacrum  aud  the  coccyx  sometimes  takes 
place. 

Closely  associated  with  the  boundary  of  the  true  pelvis  are  the  important 
sacro-sciatic  ligaments. 

The  great  or  posterior  saero-sciatic  ligament  extends  from  the  posterior 
inferior  spine  of  the  ilium,  the  lower  tubercles  of  the  sacrum,  and  the  inferior 
portion  of  the  lateral  border  of  the  sacrum  and  the  coccyx  to  the  inner  mar- 
gin of  the  ischial  tuberosity,  whence  the  fibres  are  continued  along  the  inner 
edge  of  the  adjoining  ramus  as  the  falciform  process,  the  concave  border  of 
which  affords  attachment  for  the  obturator  fascia. 

The  lesser  or  anterior  saero-sciatic  ligament,  triangular  in  form,  passes  from 
its  wide  attachment  on  the  lateral  margin  of  the  sacrum  and  the  coccyx  to  the 
spine  of  the  ischium,  thus  dividing  the  large  space  enclosed  by  the  great  sacro- 
sciatic  ligament  into  an  upper  larger  opening,  the  great  sacro-sciatic  foramen, 
and  a  lower  smaller  aperture,  the  lesser  sacro-sciatic  foramen.  The  anterior 
boundaries  of  these  foramina  are  respectively  the  greater  and  lesser  sacro- 
sciatic  notches  of  the  innominate  bone. 

Muscles  of  the  True  Pelvis. — The  osseous  and  ligamentous  framework 
of  the  true  pelvis  is  supplemented  by  muscles  and  fascia  which  complete  its 
boundaries  as  well  as  somewhat  lessen  its  capacity,  these  structures,  however, 
being  so  located  that  they  but  slightly  diminish  the  size  of  the  parturient 
canal.  In  order  to  facilitate  a  study  of  the  fasciae,  a  consideration  of  the 
muscles  related  to  the  cavity  and  floor  of  the  true  pelvis  first  claims  attention. 
These  muscles,  on  each  side,  are  four  in  number — the  obturator  internus,  the 
pyriformis,  the  levator  ani,  and  the  eoccygeus. 

The  obturator  internus  muscle  (PI.  3,  Fig.  2)  comes  in  close  relation  with  the 
pelvic  cavity  throughout  a  considerable  part  of  its  extended  origin,  which  in- 
cludes almost  the  entire  part  of  the  pelvis  contributed  by  the  innominate  bone. 
The  muscle  arises  from  the  inner  surface  of  the  obturator  membrane,  except  at 
its  lower  part,  the  fibrous  arch  completing  the  canal  for  the  obturator  vessels  and 
nerve,  and  the  inner  surface  of  the  innominate  bone  anteriorly  and  internally 
between  the  obturator  foramen  and  the  margin  of  the  pubic  arch,  and  poste- 
riorly and  externally  from  the  foramen  as  far  as  the  ilio-pectineal  line  above 
and  the  sacro-sciatic  notch  behind.  The  external  surface  of  the  muscle  rests 
upon  the  hip-bone  and  the  obturator  membrane  ;  its  inner  or  pelvic  aspect, 
below  the  line  of  origin  of  the  levator  ani  muscle,  is  covered  by  the  obtura- 
tor fascia,  the  continuation  of  the  pelvic,  and  comes  in  relation  with  the 
internal  pudic  vessels  and  accompanying  nerve. 

The  pyriformis  muscle  arises  by  digitations  from  the  second,  third,  and 
fourth  sacral  segments  between  and  external  to  the  anterior  sacral  foramina, 
from  the  ilium  below  the  inferior  posterior  spine,  and  from  the  great  sacro- 
sciatic  ligament.     In   its  course  to  the  great  sacro-sciatic  foramen,  through 


ANATOMY    OF    THE    GENERATIVE    ORGANS. 


27 


which  the  muscle  escapes  from  the  pelvis  to  seek  insertion  into  the  femur,  its 
fan-shaped  mass  aids  in  forming  the  posterior  and  outer  wall  of  the  pelvic 
cavity. 

The  remaining  two  muscles,  the  levator  ani  and  the  coccygeus,  are  of 
especial  interest,  since  they  largely  supplement  the  fascia?  in  the  formation  of 
the  septum,  or  pelvic  diaphragm,  which  stretches  across  the  bony  canal  and 
materially  aids  in  supporting  the  vagina  and  the  rectum  and  in  the  constitution 
of  the  floor  of  the  pelvis. 

The  levator  ani  (Figs.  10,  11),  the  most  important  muscle  of  the  pelvic  dia- 
phragm, in  general,  with  its  fellow  of  the  opposite  side,  presents  the  form  of  a 
horseshoe,  open  in  front,  rather  than  that  of  a  funnel,  as  very  commonly  stated. 
The  true  relations  of  this  muscle  have  especially  been  emphasized  by  Luschka 


Fig.  10.— Female  pelvis,  showing  the  form  and  attachments  of  the  levatores  ani  muscles  (Dickinson). 

and  by  Dickinson,  whose  descriptions  are  here  utilized.  These  two  muscles  con- 
stitute a  sling  attached  to  the  pubis  in  front,  and,  sweeping  almost  horizontally 
backward,  embrace  the  vagina  and  the  rectum  and  become  attached  posteriorly 
to  the  coccyx.    While  fulfilling  the  function  indicated  by  its  name,  the  action  of 


Fig.  11.— Female  pelvis,  showing  the  levatores  ani  muscles  from  before  and  below  (Dickinson). 

the  levator  ani  is  especially  to  drag  the  lower  ends  of  the  vagina  and  rectum 
forward  to  the  level  of  the  symphysis.  The  muscle  consists  of  numerous  thin 
flat  bundles  often  separated  from  one  another  by  intervals  filled  by  connective 


28  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

tissue,  by  means  of  which  all  are  united  into  a  membranous  sheet,  the  regu- 
larity of  which,  however,  is  usually  interrupted  by  the  variations  in  the 
planes  of  attachment  of  the  median  ends  of  the  component  muscular  bands. 
The  origin  of  the  levator  ani  is  partly  bony  and  partly  fascial.  The  bony 
origin  provides  for  the  anterior  and  posterior  portions  of  the  muscle,  the 
intervening  and  most  extended  part  arising  from  the  tendinous  arch  which 
bridges  over  the  obturator  interims. 

The  anterior  portion  takes  origin  principally  from  the  horizontal  ramus  of 
the  pubis,  about  1.25  centimeters  (\  inch)  from  the  middle  of  the  symphysis, 
and  3.5  centimeters  (If  inches)  below  the  upper  border  of  the  ramus. 

The  posterior  portion  is  narrow,  being  little  over  .5  centimeter  (about  J 
inch),  and  arises  from  the  inner  side  of  the  ischial  spine  in  front  of  the  origin 
of  the  coccygeus. 

The  broad  intervening  portion  of  the  muscle  springs  from  fascia  along  a 
curved  line  extending  from  the  back  of  the  pubis  to  the  ischial  spine,  the  low- 
est point  of  its  sweep  lying  5.5  centimeters  (21  inches)  below  the  ilio-pectineal 
line.  This  curved  line  of  tendinous  origin  closely  corresponds  with  the  posi- 
tion along  which  the  division  of  the  pelvic  fascia  divides  into  the  inner  recto- 
vesical lamella  and  the  obturator,  the  line  of  sepai'ation  being  marked  by 
thickening  of  the  fascia  which  produces  the  tendinous  marking  or  the  "  white 
line."  The  origin  of  the  muscular  fibres  is  by  tendinous  bands,. which  may 
not,  however,  although  closely  associated,  be  directly  connected  with  the  line. 

The  course  of  the  fibres  of  the  various  parts  of  the  muscle  varies  :  stretch- 
ing down  and  back,  the  fibres  divide  into  unequal  portions,  of  which  one 
passes  to  the  anterior  aspect  of  the  rectum,  another  to  its  posterior  and  lateral 
surfaces,  while  the  fibres  attached  to  the  pubic  bone  extend  along  the  vagina, 
with  which  they  are  united  by  strong  connective  tissue,  but  do  not  terminate 
within  its  walls.  The  belly  of  the  muscle  sweeps  backward,  almost  horizon- 
tally, surrounding  the  rectum,  the  margins  or  edges  of  the  musoular  band  being 
often  especially  thickened  ;  when  hypertrophied,  as  this  portion  of  the  muscle 
sometimes  is,  severe  vaginismus,  dyspareunia,  and  dystocia  may  result.  Accord- 
ing to  the  observations  of  Dickinson,  the  inner  edge  of  the  levator  ani  lies 
about  1.5  centimeters  from  the  vaginal  orifice,  the  position  of  the  muscle  being 
indicated  by  a  sharply  defined  double  band.  Contraction  of  the  muscle  causes 
the  upper  end  of  the  vaginal  canal  to  rise  from  15°  to  20°  toward  the  pelvic 
brim.     The  average  muscle  exerts  a  power  of  ten  pounds. 

The  insertion  of  the  post-rectal  part  of  the  levator  ani  varies  with  its  posi- 
tion :  the  posterior  and  smallest  part  is  attached  by  tendon  to  the  front  of  the 
fourth  coccygeal  vertebra ;  the  middle  part  becomes  aponeurotic  and  joins  its 
fellow  at  the  tip  of  the  coccyx  ;  and  the  anterior  and  largest  part  unites 
directly,  without  tendinous  structure,  with  the  muscular  bundles  of  the  oppo- 
site side. 

The  coccygeus  muscle  supplements  the  levator  ani  behind,  presenting  a  tri- 
angular sheet  which  passes  from  the  ischial  spine  to  the  adjacent  surfaces  of 
the  coccyx  and  the  sacrum.  The  muscle  arises  by  its  apex  from  the  spine  of 
the  ischium  and  from  the  inner  surface  of  the  pelvic  fascia,  and  expands  to  be 


ANATOMY    OF    THE    GENERATIVE    ORGANS. 


29 


inserted  by  its  base  into  the  lateral  margin  of  the  coccyx  and  the  lower  part 
of  the  sacrum.  The  pelvic  surface  of  this  muscle  aids  in  supporting  the  rec- 
tum, and  its  external  surface  is  closely  related  with  the  lesser  sacro-sciatic 
ligament. 

Fasciae  of  the  Pelvis. — The  pelvic  fascia  is  the  direct  continuation  of 
the  iliac  and  transversalis  fascial  sheets.  It  is  attached  laterally  along  the 
pelvic  brim  and  around  the  origin  of  the  obturator  interims,  and  behind  it 
extends  over  the  pyriformis  and  the  adjacent  nervous  trunks  as  far  as  the 
sacrum ;  anteriorly  it  closely  follows  the  outline  of  the  obturator  interims,  aids 
in  bounding  the  inner  opening  of  the  obturator  canal,  and  at  the  lower  part 
of  the  pubic  symphysis  becomes  attached  to  the  anterior  pelvic  wall. 

A  thickened  baud  of  light  colored  fascia,  the  so-called  "white  line"  (see  p. 
28),  which  extends  from  the  lower  part  of  the  posterior  surface  of  the  symphy- 
sis to  the  ischial  spine,  indicates  the  position  along  which  an  inner  or  visceral 


Fig.  12.— Sagittal  seclion  showing  relations  of  the  several  layers  of  fascia  within  the  pelvic  floor  (Dickinson). 

lamella,  the  recto-vesical  fascia,  diverges  from  the  parietal  or  main  pelvic 
sheet ;  the  latter,  which  adheres  to  the  pelvic  wall  and  covers  the  obturator 
interims  muscle,  is  now  known  as  the  obturator  fascia;  the  latter,  therefore, 
is  that  part  of  the  parietal  lamella  of  the  pelvic  fascia  that  lies  below  the 
"  white  line "  and  forms  the  external  fascial  investment  of  the  ischio-rectal 
fossa,  the  deep  triangular  recess  included  between  the  ischial  tuberosity  and 
the  contiguous  parts  of  the  innominate  bone  and  the  external  and  inferior  sur- 
face of  the  muscles  of  the  pelvic  diaphragm.  A  thin  sheet  given  off  from 
the  parietal  layer  or  obturator  fascia  below  the  ''white  line"  covers  the  under 


30  AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 

surface  of  the  levator  ani  muscle  and  constitutes  the  anal  or  ischiorectal  fascia. 
The  internal  pudic  blood-vessels  and  the  accompanying  nerve  in  their  course 
across  the  outer  wall  of  the  ischio-rectal  fossa  are  invested  by  an  additional 
special  layer  of  the  obturator  fascia,  which  thus  separates  the  vessels  from  the 
fossa  and  encloses  them  within  Alcock's  canal. 

The  visceral  lamella,  or  the  recto-vesical  fascia,  is,  as  pointed  out  by  Webster, 
a  structure  of  great  importance  in  enabling  the  pelvic  floor  to  resist  inter- 
abdominal  pressure  at  the  pelvic  outlet.  Springing  from  the  parietal  layer 
along  the  "  white  line,"  the  recto-vesical  fascia  covers  the  inner  and  upper  sur- 
face of  the  levator  ani  and  continues  over  that  muscle  to  the  bladder,  the 
vagina,  and  the  rectum,  where  it  divides  into  four  layers — the  vesical,  the 
vesico-vaginal,  the  recto-vaginal,  and  the  rectal. 

The  vesical  layer  expands  over  the  lower  lateral  aspect  of  the  bladder, 
forming  of  that  organ  the  lateral  true  ligaments,  which  become  greatlv  thinned 
out  as  they  pass  over  its  walls.  The  anterior  part  of  the  visceral  lamella  on 
each  side  is  attached  to  the  back  of  the  lower  part  of  the  pubis  in  front,  lat- 
erally to  the  symphysis,  and  behind  passes  to  the  anterior  surface  of  the  bladder 
to  become  the  anterior  true  ligament  of  this  organ  :  the  "space  between  these 
bands,  the  pubis,  and  the  bladder,  sometimes  called  the  "  space  of  Retzius,"  is 
occupied  by  the  retropubic  tissue,  consisting  principally  of  adipose  and  areolar 
tissue. 

The  vesico-vaginal  layer  extends  between  the  bladder  and  the  anterior 
vaginal  wall,  and  aids  in  connecting  these  parts  by  its  firm  union  with  both, 
blending  with  the  attachment  of  the  posterior  part  of  the  bladder  to  the 
uterine  cervix. 

The  recto-vaginal  layer  passes  between  the  vagina  and  the  adjacent  wall  of 
the  lower  part  of  the  rectum ;  the  union,  except  behind  the  upper  part  of  the 
vagina,  is  very  intimate,  while  below,  this  layer  is  continuous  with  the  fibrous 
tissue  of  the  perineal  body.  ' 

The  rectal  layer  extends  behind  the  rectum  and  is  attached  to  its  walls, 
becoming  continuous  with  the  corresponding  layer  of  the  opposite  side. 

The  Pelvic  Floor. — The  exact  structures  which  should  be  regarded  as 
taking  part  in  the  constitution  of  the  pelvic  floor  has  occasioned  much  dis- 
cussion, since  by  some  authors  its  constituents  are  limited  to  those  structures 
which  directly  contribute  to  the  continuity  of  the  septum  closing  in  the  pelvic 
outlet,  while  by  others  all  parts  directly  or  indirectly  contributing  to  the  support 
of  this  septum,  as  the  bladder,  the  upper  part  of  the  vaginal  canal,  the  uterus, 
and  the  rectum,  are  included  within  the  category  of  the  floor. 

In  the  present  consideration  of  the  pelvic  floor  only  those  structures  will 
be  included  that  directly  contribute  to  its  formation,  thus  excluding,  with 
Symington,  the  bladder  and  the  uterus,  and  reckoning  as  belonging  to  the  floor 
only  those  portions  of  the  walls  of  the  vagina  and  of  the  rectum  that  lie  inti- 
mately united  with  the  septum.  The  close  relation  which  these  excluded 
organs  bear  to  the  pelvic  floor,  however,  must  not  be  overlooked,  since  by 
their  intimate  connection  with  the  tissues  of  the  floor,  on  the  one  hand,  and  by 


ANATOMY   OF    THE    GENERATIVE    ORGANS. 


31 


their  suspensory  apparatus,  on  the  other  hand,  they  exert  an  important  influ- 
ence, as  emphasized  by  Webster,  in  supporting  the  tissues  closing  the  outlet 
of  the  pelvis. 

The  pelvic  floor,  in  the  sense  here  accepted,  is  bounded  externally  by  the 
skin  and  internally  by  the  peritoneum,  and  includes  the  several  intervening 
structures  which  stretch  across  between  the  osseo-ligamentous  boundaries  of 
the  pelvis  and  enclose  the  irregular  outlet  of  its  cavity.  Viewed  in  mesial 
sagittal  section,  the  floor  is  seen  to  be  divided  by  the  vaginal  slit  into  two 
portions,  an  anterior  and  a  posterior,  which  have  been  designated  by  Hart, 
respectively,  as  the  pubic  and  the  sacral  segments. 

The  anterior  or  pubic  segment  appears  triangular,  being  attached  to  the 
pelvis  in  front,  and  including  the  structures  lying  between  the  symphysis  and 
the  vaginal  orifice ;  the  urethral  and  the  anterior  vaginal  walls,  together  with 
the  dense  intervening  fibrous  tissues,  contribute  largely  to  this  portion  of  the 
floor. 

The  posterior  or  sacral  segment  includes  the  structures  between  the  vaginal 
orifice  and  the  posterior  bony  pelvic  wall,  to  the  sides  of  which  it  is  closely 
attached.  The  portion  of  this  segment  interposed  between  the  vaginal  slit  and 
the  anus  constitutes  the  important  perineal 
body  (Fig.  13),  whose  elastic  yet  resistant 
tissues  enable  the  septum  to  undergo  great 
distention  during  labor.  The  perineal  body 
is  triangular  in  sagittal  section,  and  its 
boundaries  are  the  posterior  vaginal  wall 
in  front,  the  anterior  wall  of  the  rectum 
behind,  and  the  integument  between  the 
vagina  and  the  anus  below.  The  base  of 
the  perineal  body  measures  about  2.6  cen- 
timeters, and  the  height  from  3.0  to  3.6 
centimeters.  In  addition  to  the  strong 
bundles  of  fibro-elastic  tissue  and  invol- 
untary muscle  that  constitute  the  body, 
it  is  traversed  by  the  muscles  which  join  in  the  common  tendinous  perineal 
centre. 

The  female  perineum  proper — by  which  term  is  to  be  understood  the 
anterior  portion  of  the  pelvic  floor  included  between  the  ischio-pubic  rami  as 
far  back  as  a  line  drawn  through  the  tubera  ischii — corresponds  in  general 
with  the  similarly  situated  structures  in  the  male,  subject  to  the  modifica- 
tion brought  about  by  the  mesial  cleavage  of  the  parts  by  the  vulvo-vaginal 
opening.  The  perineum  must  be  distinguished  from  the  perineal  body,  the 
latter  including  only  the  limited  tissues  intervening  between  the  vagina  and 
the  anus. 

As  in  the  male,  so  also  in  the  female  perineum,  the  fascia?  constitute  im- 
portant and  resistant  structures  (Figs.  14-16).  Of  these  structures  there  are 
three :   the  deep  layer  of  the  superficial   fascia  (corresponding   with   Colles' 


Fig.  IS.— Sagittal  section  of  the  perineal  body, 
showing  its  component  structures  (life  size). 


32 


AMEBIC  AX   TEXT-BOOK    OF    OBSTETBICS. 


fascia),  the  superficial  or  inferior,  and  the  deep  or  superior  layer  of  the  trian- 
gular ligament.  These  fascial  layers  are  attached  at  various  levels  to  the 
ischio-pubic  rami  anteriorly  and  laterally,  and  converge  as  they  proceed  back- 


External  j 

Internal  superficial 

rineal  j 
Superficial  perineal 


Infer 

rhoidal  artery. 

rhoidal  . 
Tendinous  centre  of 


Fig.  14.— Superficial  structures  of  the  female  perineum  (Weisse). 

ward  to  become  continuous  at  the  posterior  free  border  of  the  so-called  "  peri- 
neal shelf,"  the  middle  of  which  marks  the  perineal  centre. 

The  interval  enclosed  between  the  superficial  fascia  and  the  superficial  or 
inferior  layer  of  the  triangular  ligament  is  divided  by  the  genital  orifice  into 
two  triangular  spaces  which  together  correspond  with  the  superficial  perineal 
interspace.  The  various  structures  contained  within  this  space  include  the 
crura  of  the  clitoris  with  the  associated  ischio-cavernosus  muscles ;  the  bulbi 
vestibuli,  with  the  sparingly  developed  constrictores  vagina,  the  homologues 
of  the  bulbo-cavernosus;  the  superficial  transversi  perinsei;  the  glands  of  Bar- 
tholin ;  together  with  the  superficial  perineal  vessels  and  nerves. 

On  removal  of  the  skin  and  the  superficial  fascia  the  ischio-cavernosus  muscles 
appear  as  slender  bands  which  arise  from  the  inner  surface  of  the  tuberosities 
and  rami  of  the  ischium  and  the  pubic  rami,  and  converge  toward  the  anterior 
commissure  of  the  genital  fissure,  to  be  inserted  into  the  cavernous  bodies  of 
the  clitoris,  these  muscles  corresponding  closely  with  those  of  the  male  except 
in  size,  their  reduced  dimensions  agreeing  with  the  diminutive  clitoris. 

The  bulbo-cavernosus,  or  constrictor  vaginae  muscle,  is  represented  by  atten- 
uated fibres  which  pass  on  either  side  of  the  vaginal  orifice  over  the  bulbi  ves- 
tibuli and  the  slender  stalks  connecting  them  with  the  clitoris.  The  action  of 
these  fibres  seems  to  be  largely  confined  to  exerting  pressure  upon  the  adjacent 


ANATOMY   OF    THE    GENERATIVE    ORGANS. 


33 


masses  of  erectile  tissue,  with  little,  if  any,  direct  role  as  constrictors  of  the 
vagina,  compression  of  this  canal  being  exercised,  as  already  stated,  by  the 
contractions  of  the  anterior  portions  of  the  levator  ani  muscle. 

The  superficial  transversus'  perincei  muscles  closely  resemble  those  of  the 
male,  being,  however,  reduced  in  size.  They  arise  from  the  inner  surface  of 
the  tuberosities  and  rami  of  the  ischium,  in  close  relation  with  the  origin  of 
the  ischio-cavernosi,  and  extend  inward  toward  the  perineal  centre,  where  they 
blend  with  the  fibres  of  the  sphincter  ani  and  the  constrictores  vaginae. 

The  roof  of  the  superficial  interspace  is  formed  by  the  inferior  or  superficial 
layer  of  the  triangular  ligament,  the  somewhat  thickened  anterior  part  of  the 


Dorsalartery  of  clitoris. 
Inferior  pudendal 


Inferior  hemorrhoidal 
Inferior  hemorrhoidal 


Fig.  15.— Dissection  of  female  perineum:  on  the  left  side  the  perineal  muscles  are  exposed  by  the 
reflection  of  the  perineal  fascia  ;  on  the  right  side  the  muscles  and  the  superficial  layer  of  the  triangular 
ligament  have  been  removed,  thereby  exposing  the  deep  layer  of  the  ligament  (modified  from  Weisse). 

deep  fascia  of  the  perineum.  This  layer  is  attached  antero-laterally  to  the 
pubo-ischial  rami  above  the  line  of  attachment  of  the  superficial  fascia,  and 
stretches  almost  horizontally  across  the  subpubic  arch  to  the  posterior  perineal 
border,  where  it  fuses  with  the  other  layers  taking  part  in  the  perineal  ledge. 

The  superior  or  deep  layer  of  the  triangular  ligament  is  a  resistant  fibrous 
septum  which  expands  inward  on  each  side  from  its  line  of  attachment  along 
the  ischio-pubic  rami  and  constitutes  the  floor  of  the  anterior  extensions  of  the 
ischio-rectal  fossse,  at  the  posterior  margin  of  the  perineal  ledge  joining  the 
superficial  layer  in  the  common  fusion  of  the  fascial  layers  occurring  at  that 
point.  This  layer  may  be  regarded  as  a  reflection  derived  from  both  the 
obturator  and  the  recto-vesieal  fascia,  since  the  septum  is  formed  by  the  union 
of  the  contribution  given  off  laterally  from  the  obturator  fascia  with  that  sup- 


34  AMERICAN  TEXT-BOOK   OF   OBSTETRICS. 

plied  mesially  by  the  recto-vesical  fascia  :  this  relation  is  especially  evident  in 
frontal  sections  passing  through  the  ischial  tuberosities. 

The  deep  perineal  interspace  lies  between  the  inferior  and  superior  layers  of 
the  triangular  ligament,  and  it  contains  within  its  wedge-shaped  area  the  urethra 
and  the  surrounding  venous  plexuses,  the  internal  pudic  arteries  and  accom- 
panying veins  and  deeper  nerves,  and  the  fibres  of  the  deep  transversus  peri- 
nsei  muscle,  here  divided  by  the  genital  fissure,  and  represented  by  thin  groups 
of  variable  muscular  tissue  surrounding  the  urethra. 

On  removing  the  skin  and  fascia,  that  part  of  the  pelvic  floor  lying  poste- 
rior to  the  perineum  proper  is  divided  by  a  median  ridge  extending  from  the 


^J*** 


I      .<0f        • 


m 


Fig.  16.— Dissection  of  female  perineum,  showing  the  deeper  structures  after  removal  of  the  levator  and 
sphincter  ani  muscles  (much  modified  from  Weisse). 

perineal  centre  to  the  tip  of  the  coccyx,  that  consists  of  the  lower  end  of  the 
rectum  surrounded  by  the  deep  muscular  band  of  the  sphincter  ani  externus. 
This  muscle  comprises  voluntary  fasciculi  which  extend  from  the  perineal 
centre  in  front,  where  they  blend  with  the  fibres  of  the  superficial  transverse 
perineal  and  vaginal  constrictor,  to  the  tip  of  the  coccyx  behind,  enclosing  the 
anus  in  their  course.  Superficially  the  anal  sphincter  is  closely  related  with 
the  integument,  deeply  with  the  levatores  ani  and  the  internal  sphincter ;  the 
muscular  tissue  of  the  rectum  is  closely  related  to  the  external  sphincter,  since 
numerous  bands  of  the  former  blend  with  the  encircling  fasciculi  of  the 
sphincter.  Externally  the  anal  sphincter  comes  in  contact  in  its  deeper  parts 
with  the  tissue  occupying  the  ischio-rectal  fossse ;  the  latter  extend  as  two 


ANATOMY   OF    THE    GENERATIVE    ORGANS. 


35 


deeply  receding  spaces  whose  superior  boundary  follows  the  lower  surface  of 
the  levatores  ani. 

The  ischio-redal  fossce  are  continued  anteriorly  and  posteriorly  within  the 
pockets  situated  respectively  above  the  triangular  ligament  and  the  sacro-sciatic 
ligaments.     Viewed   in   sagittal  sections  passing  through   these  recesses,  the 


Fig.  17.— Dissection  of  female  perineum,  showing  superficial  blood-vessels  and  nerves  (Savage) :  C, 
clitoris;  M,  meatus  urinarius ;  V,  vaginal  orifice;  A,  anus;  0,  coccyx;  T,  tuber  ischii;  L,  sacro-sciatic 
ligament ;  1,  6,  internal  pudic  artery,  giving  off  its  inferior  hemorrhoidal  (3),  cutaneous,  and  muscular 
branches  (2,  4) ;  5,  superficial  perineal ;  S,  artery  of  bulb ;  7,  9,  terminal  branches  going  to  dorsum  and 
cavernous  bodies  of  clitoris ;  10,  pudic  nerve  ;  11,  hemorrhoidal  and  muscular  (12)  branches ;  13, 14,  inter- 
nal and  external  superficial  perineal  nerves ;  15,  communications  with  inferior  pudendal  nerve  (16) ;  17, 
continuation  of  deep  branch  of  pudic  nerve,  terminating  as  dorsal  nerve  of  clitoris  (IS) ;  19,  terminal 
twigs  of  ilio-inguinal  nerve ;  20,  small  sciatic;  21,  cutaneous  branches;  a,  cut  surface  of  gluteus  maxi- 
mus;  6,  sphincter  ani;  c,  levator  ani;  d,  transversus  perinei ;  e,  bulbo-cavernosus ;  /,  gracilis;  g,  ischic- 
cavernosus ;  h,  expansion  of  cms  clitoridis  ;  i,  adductor  magnus. 

ischio-rectal  fossa  presents  an  outline,  as  described  by  Anderson,  not  unlike 
that  of  an  anvil.  In  frontal  sections  the  fossa  appears  as  an  open  A-shaped 
recess  except  at  its  extreme  ends,  where,  as  just  described,  the  perineal  ledge 
and  the  sacro-sciatic  ligaments  close  in  the  space  below. 

The  blood-vessels  of  the  pelvic  floor  include  the  arterial  branches  derived 


36  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

directly  or  indirectly  from  the  anterior  division  of  the  internal  iliac,  and  the 
venous  trunks  accompanying  the  arteries,  as  well  as  the  venous  plexuses  occur- 
ring in  close  relation  with  the  vesico- vaginal  walls  (Fig.  17). 

The  inferior  vesical  and  the  vaginal  arteries,  together  with  twigs  from  the 
external  pudic,  supplement  the  branches  derived  from  the  internal  pudic,  of 
which  the  inferior  hemorrhoidal  and  the  superficial  perineal  especially  supply 
the  muscular  structures  connected  with  the  pelvic  floor.  The  superficial  peri- 
neal artery  pierces  the  superficial  fascia  and  gains  the  superficial  perineal 
interspace,  supplying  the  contiguous  structures  and  giving  off  the  transverse 
perineal  branch. 

The  continuation  of  the  internal  pudic  artery  maintains  a  more  deeply  situ- 
ated course,  lying  along  the  lateral  boundary  of  the  deep  perineal  interspace 
between  the  two  layers  of  the  triangular  ligament.  In  this  position  are  given 
off  the  arteries  of  the  vestibular  bulbs  and  of  the  crura  of  the  clitoris.  The 
internal  pudic  terminates,  after  piercing  the  anterior  layer  of  the  triangular 
ligament,  as  the  dorsal  artery  of  the  clitoris,  from  which  twigs  extend  to  the 
corpus  cavernosum,  the  glans,  and  the  prepuce. 

The  veins  of  the  pelvic  floor  consist  of  the  trunks  which  closely  correspond 
with  the  arteries,  of  which  veins  the  most  important  are  the  tributaries  of  the 
pudic  vein  and  those  which  pursue  an  independent  course  and  take  part  in  the 
formation  of  the  rich  vesico-vaginal  and  hemorrhoidal  plexuses. 

The  nerves  supplying  the  structures  of  the  floor  are  derived  principally 
from  branches  of  the  sacral  nerves,  either  directly  or  after  their  formation  of 
the  plexus,  supplemented  by  some  few  filaments  from  the  ilio-inguinal  as  well 
as  by  numerous  branches  from  the  neighboring  hypogastric  plexus  of  the 
sympathetic  (PI.  4). 

The  anterior  division  of  the  fourth  sacral  nerve  supplies  important  muscu- 
lar structures,  including  the  levator  ani,  the  sphincter  ani,  and,  in  conjunction 
with  the  fifth  sacral,  the  coccygeals. 

The  superficial  perineal  branches  of  the  pudic  and  the  inferior  pudendal 
branch  of  the  small  sciatic  nerve  chiefly  provide  for  the  integument  and  the 
more  superficial  structures  of  the  pelvic  floor,  including  the  perineal  muscles 
(the  ischio-cavernosi,  the  constrictor  vaginae,  and  the  transversi  perinsei)  and 
the  more  external  portions  of  the  genitalia;  the  ilio-inguinal  contributes  fila- 
ments to  the  labia.  The  termination  of  the  pudic  nerve  passes  forward  as 
the  diminutive  dorsal  nerve  of  the  clitoris.  Sympathetic  filaments  from  the 
hypogastric  plexus  are  additionally  distributed  to  those  parts  containing 
abundant  vascular  tissue. 

II.  Anatomy  op  the  Female  Generative  Organs. 

The  structures  constituting  the  female  reproductive  apparatus  consist  of 
three  groups — (1)  the  external,  ("2)  the  intermediate,  and  (3)  the  internal 
generative  organs. 

1.  External  organs  of  generation  (PI.  5),  or  the  genitalia,  include  the 
mons  veneris,  the  labia  majora  and  minora,  the  clitoris,  the  vestibule  with  the 


ANATOMY  OF  THE  PELVIC  FLOOR. 


Plate  4. 


ANATOMY   OF   THE    GENERATIVE    ORGANS.  37 

meatus  urinarius,  and  the  vaginal  orifice.  These  parts  are  collectively  known 
as  the  vulva  or  pudendum. 

The  mons  veneris  presents  au  eminence  surmounting  the  pubes  in  advance 
of  the  vulva,  and  is  composed  of  stout  integument  abundantly  supplied  with 
crisp  hairs,  and  a  thick  cushion  of  subcutaneous  adipose  and  areolar  tissue 
upon  which   the  rounded  contour  of  the  part  depends. 

The  labia  majora,  the  homologues  of  the  scrotum  in  the  male,  are  two  con- 
spicuous longitudinal  folds  of  integument  extending  from  the  mons  veneris 
downward  and  backward  to  within  about  2.5  centimeters  (1  inch)  in  front 
of  the  anus.  The  elongated  fissure  included  between  these  folds,  the  uro- 
genital orifice,  occupies  almost  a  horizontal  position  in  the  erect  posture,  and  is 
limited  by  the  anterior  and  the  posterior  commissure,  formed  by  the  union  of 
the  labia  in  front  and  behind.  Immediately  within  the  posterior  commissure 
a  crescentic  fold  extends  transversely  and  constitutes  the  fourchette  ;  the  space 
between  the  latter  and  the  posterior  commissure  is  the  fossa  navicularis. 

The  labia  majora  are  continuous  anteriorly  with  the  mons  veneris,  and  are 
thicker  in  front  than  behind  ;  they  present,  the  usual  appearance  of  integument, 
being  covered  on  their  outer  surfaces  with  scattered  hairs  and  pigmented 
epidermis ;  their  protected  inner  surfaces  are  more  delicate  in  texture  than 
their  outer  surfaces,  and  where  least  exposed  they  partake  somewhat  of  the 
character  of  a  mucous  membrane. 

The  tegmental  fold  of  each  labium  includes  areolar  tissue,  some  involun- 
tary muscle,  and  a  considerable  mass  of  fat  which  receives  the  distal  end  of  the 
round  ligament  of  the  uterus.  Descent  of  the  ovary  into  the  labium  occurs  in 
very  exceptional  cases,  the  displaced  organ  following  the  round  ligament  and 
taking  up  a  position  within  the  labium  after  traversing  the  inguinal  canal. 
The  labia  in  the  young  and  well-developed  subject  are  closely  approximated 
and  occlude  the  vaginal  orifice. 

The  labia  minora,,  or  the  nymphce,  are  two  thin  diverging  folds  of  delicate 
skin  that  lie  protected  within  the  greater  labia,  so  that  their  arched  free 
borders  are  often  completely  covered  and  not  visible  externally ;  unless  arti- 
ficially separated  their  mesial  surfaces  lie  in  close  contact.  The  nymphse 
are  subject  to  great  individual  variation  in  size,  in  some  cases,  as  conspic- 
uously seen  in  Hottentot  women,  reaching  excessive  dimensions ;  usually  they 
extend  downward  and  backward  from  the  clitoris  (about  3.5  centimeters) 
along  the  genital  fissure,  fading  away  at  the  sides  of  the  vaginal  orifice. 
Directly  continuous  with  the  labia  majora  externally,  their  smooth  inner 
surfaces  pass  directly  into  the  mucous  membrane  of  the  adjacent  vestibule, 
which  they  closely  resemble  in  appearance  and  structure.  Vascular  papilla? 
and  well-developed  sebaceous  follicles  are  common  to  both  surfaces  of  the 
nymphse,  but  sweat-glands,  hairs,  and  fat  are  wanting.  The  interior  of  each 
fold  contains  abundant  venous  spaces,  which,  in  connection  with  the  unstriped 
muscle  present,  produce  a  structure  resembling  erectile  tissue. 

The  converging  and  often  unsymmetrical  labia  minora,  just  before  meeting 
anteriorly,  separate  into  two  divisions,  the  outer  and  upper  leaflets  continuing 


38  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

over  the  clitoris  to  unite  to  form  the  preputium  clitoridis,  the  lower  or  inner 
lamina?  joining  below  the  glands  to  constitute  the  frenum  clitoridis. 

The  clitoris,  the  homologue  of  the  penis,  presents  great  similarity  to  the 
male  organ,  possessing  all  the  parts  of  the  latter  reduced  in  size  and  influenced 
by  the  absence  of  the  urethra  and  by  the  cleft  and  modified  condition  of  the 
corpus  spongiosum  as  represented  by  the  bulbi  vestibuli. 

The  somewhat  laterally  compressed  body  of  the  clitoris  consists  of  the  dimin- 
utive corpora  cavernosa,  which  diverge  behind  and  are  attached  by  their  crura 
along  the  pubic  and  ischial  rami,  the  suspensory  ligament  aiding  in  maintain- 
ing the  position  of  the  organ.  In  front  the  cavernous  bodies  are  capped  by  the 
rounded  glans  clitoridis,  which  contains  papillae  occupied  by  arterial  tufts  and 
the  peculiar  special  nerve-endings,  the  genital  corpuscles.  The  nerves  of  the 
clitoris  are  relatively  better  developed  than  the  corresponding  ones  of  the 
penis,  the  organ  being  the  especial  seat  of  voluptuous  sensation.  Sebaceous 
follicles  surround  the  glans,  and  they  are  also  present  in  the  outer  layer  of  the 
prepuce,  being  almost  wanting,  however,  on  the  glans  itself.  These  follicles 
secrete  substances  prone  to  decomposition  and  to  the  production  of  a  peculiar 
odor.  The  erectile  tissue  constituting  the  diminutive  corpora  cavernosa  and 
the  glans  corresponds  in  structure  with  similar  tissues  within  the  penis.  Two 
small  muscles,  the  ischio-cavernosi  or  erectores  clitoridis,  extend  from  the 
ischial  tuberosities  to  be  inserted  in  the  crura  of  the  clitoris,  and  correspond 
with  the  homologous  muscles  of  the  male. 

The  vestibule  includes  the  triangular  space  lying  between  the  clitoris  in 
front,  the  vaginal  orifice  behind,  and  the  nymphse  at  the  sides.  Its  smooth 
mucous  surface  is  broken  by  the  urethral  opening,  the  meatus  urinarius 
being  situated  in  the  mid-line  of  the  posterior  vestibular  wall  about  2  to 
2.5  centimeters  (1  inch)  behind  the  clitoris,  slightly  in  advance  of  the 
orifice  of  the  vagina. 

The  urinary  meatus  varies  in  form,  but  oftenest  appears  as  an  ovoid  cleft, 
frequently  presenting  short  irregular  lateral  branches,  surrounded  by  a  border 
of  slightly  corrugated  elevated  mucous  membrane,  due  to  the  encircling  ring 
of  muscular  fibres  (PI.  5). 

The  bidbi  vestibuli  are  two  elongated  leech-shaped  masses  (about  2.5  centi- 
meters in  length)  situated  on  either  side  of  the  vestibule  a  little  behind  the 
nymphse,  and  attached  above  to  the  crura  of  the  clitoris  by  means  of  a  con- 
tracted intermediate  portion,  thenars  intermedialis.  They  are  composed  prin- 
cipally of  close  and  intricate  venous  plexuses  corresponding  with  the  tissues  of 
the  male  corpus  spongiosum,  of  wdiich  part  the  bulbi  vestibuli  must  be  regarded 
as  the  cleft  homologue.  The  constrictores  vaginas  muscles  lie  in  close  relation 
with  the  bulbs,  and  by  their  contractions,  as  during  sexual  excitement,  com- 
press the  venous  channels  and  render  the  tissue  turgid  and  erect. 

The  glands  of  Bartholin,  the  homologues  of  Cowper's  glands,  are  two 
round  or  oval  yellowish  bodies  (about  1  centimeter  in  diameter)  which  lie  on 
either  side  of  the  lower  part  of  the  vagina.  These  bodies  are  less  deeply 
situated  than  the  corresponding  structures  in  the  male,  being  contained  within 


EXTERNAL  GENEEATIVE  ORGANS. 


1.  Virgin  hymen.  2.  Characteristic  hymen  and  fourehette  of  a  married  woman ;  large  wrinkled  labia 
minora  and  prepuce.  3.  Multipara,  showing  remnant  of  hymen,  pouching  anterior  and  post-vaginal  wall, 
scar  in  perineum,  large  labia  majora.    4.  Diagram  on  a  different  scale  from  the  preceding  figures. 


ANATOMY  OF   THE    GENERATIVE    ORGANS. 


39 


the  superficial  perineal  interspace,  and  not  between  the  two  layers  of  the  tri- 
angular ligament.  They  are  muco-serous  racemose  glands,  and  pour  their 
secretion  upon  the  mucous  membrane  by  long  slender  ducts  which,  after  au 
oblique  course,  open  into  the  vestibule  just  external  to  the  vaginal  orifice. 


Dorsal  nerve  of 
clitoris. 
*orsal  artery 
of  clitoris. 

Artery  of  corpus 


i 


Fig.  18.— Dissection  of  female  perineum,  showing  the  vestibular  bulb  and  the  clitoris  (Weisse). 

The  hymen  consists  of  a  thin,  usually  crescentic  duplicative  of  mucous 
membrane,  strengthened  by  fibrous  tissue,  stretched  across  the  posterior  part  of 
the  vaginal  opening,  which  it  partly  occludes.  The  hymen  varies  greatly  in 
form  and  in  extent,  at  times  being   represented  by  a  slight  semilunar  fold 


Fig.  19.— Erectile  structures  of  the  female  genitalia,  particularly  the  highly  vascular  bulbi  vestibuli 

(Kobelt). 

whose  concavity  looks  upward  toward  the  pubes,  at  other  times  forming  almost 
a  complete  and  imperforate  membranous  septum.  The  variations  in  the  shape 
and  extent  of  the  fold  and  its  orifice  include  the  circular,  cleft-like,  cordiform, 
cribriform,   and   other  types,   well   illustrated   on   Plate   6.     Rupture  of  the 


40 


AMERICAN    TEXT-BOOK    OF   OBSTETRICS. 


hymen  usually,  but  by  no  means  necessarily,  occurs  during  the  first  sexual 
intercourse ;  in  rare  cases  the  septum  persists  until  the  event  of  parturition. 
In  women  who  have  borne  children  the  orifice  of  the  vagina  is  surrounded  by 
irregular  papillary  elevations,  the  carunculce  myrtiformes :  these  are  tne  remains 
of  the  ruptured  hymen,  but  are  usually  present  only  after  labor  has  taken 
place,  since,  as  established  by  Schroeder,  the  rent  hymen  is  converted  into  these 
eminences  as  the  result  of  the  pressure  incident  to  childbearing,  and  not  to  coitus. 


Dorsal  artery. 
Dorsal  vein   of 
clitoris. 


Deep  perineal  muscle. 

Superficial  layer  of  trian- 
gular ligament  reflected. 

Deep  layer  of' superficial 
perineal  fascia  reflected. 

Fig.  20.— Dissection  of  female  perineum,  showing  structures  within  the  deep  interfascial  perineal 
interspace ;  the  vulvo- vaginal  glands,  however,  belong  to  the  superficial  space,  but  are  she  TO  resting  on 
the  deeper  structures  (Weisse). 

The  female  urethra  (Fig.  21)  is  short,  being  only  about  4  centimeters  in 
length,  and  lies  beneath  the  symphysis  pubis,  firmly  imbedded  within  the  ante- 
rior vaginal  wall.  It  descends  from  the  neck  of  the  bladder  to  the  vestibule 
almost  vertically,  presenting  usually,  however,  a  slightly  marked  double  or  sig- 
moid curve,  or  at  least  a  curvature,  forward.  Its  vestibular  orifice,  the  meatus 
urinarius,  is  indicated  usually  by  an  elevation  of  the  mucous  membrane  situated 
from  2  to  2.5  centimeters  behind  the  clitoris.  The  meatus  marks  the  most  con- 
stricted part  of  the  canal,  the  average  diameter  of  which  is  about  .6  centimeter. 
Owing  to  the  elastic  character  of  its  tissues  and  to  the  yielding  nature  of  the 
surrounding  structures,  the  female  urethra  is  capable  of  great  distention,  a 
matter  of  importance  in  examination  of  the  bladder. 

The  walls  of  the  urethra  comprise  a  mucous,  a  submucous,  and  a  muscular 
layer.  The  mucosa  is  covered  by  stratified  squamous  or  transitional  epithelium 
directly  continuous  with  that  of  the  bladder ;  tubular  glands  occur  near  thes 
vesical  end  of  the  canal,  where  the  mucous  membrane  is  soft  and  spongy. 
Skene  has  called  attention  to  the  existence  of  two  small  tubes  (from  10  to  20 
millimeters  in  length)  which  lie  within  the  muscular  walls  of  the  female 
urethra  and  which  open  by  minute  orifices  situated  about  3  to  4  millimeters 
within  or  above  the  meatus.  These  tubes  probably  represent  the  remains  of 
Gartner's  duct  derived  from  the  fetal  Wolffian  duct. 


EXTERNAL  GENERATIVE  ORGANS. 


Plate  6. 


„-  a 


L__ 


ANATOMY   OF   THE    GENERATIVE   ORGANS. 


41 


The  submucous  stratum  contains  much  elastic  tissue  and  a  rich  venous 
plexus.  The  muscular  tissue  of  the  bladder  is  continued  over  the  urethra  as 
an  inner  longitudinal  and  an  outer  circular  layer,  in  addition  to  which  the 
tube  receives  an  investment  between  the  layers  of  the  triangular  ligament 
from  the  compressor  urethra?  or  deep  transverse  perineal  muscle.  The  numer- 
ous blood-vessels  and  nerves  of  the  female  urethra  are  derived  from  the  same 
sources  as  those  of  the  vagina. 

The  female  bladder,  relatively  broad  and  capacious,  bears  important  rela- 
tions to  the  vagina  and  the  uterus.  When  empty  and  relaxed  the  organ  lies 
entirely  within  the  true  pelvis,  behind  the  pubes  and  usually  to  one  side;  the 
fundus  is  then  greatly  flattened  out  and  somewhat  indented,  so  that  the  cavity 
of  the  bladder  and  the  urethra  together  appear  Y-shaped  in  section  (Fig.  22),  the 
widely-separated  hinder  limb  and  the  corresponding  posterior  vesical  wall  lying 
against  the  upper  part  of  the  vagina  and  the  lower  segment  of  the  uterus ; 


Fig.  21.— Sagittal  section,  showing  relations  and  form  especially  of  the  bladder,  urethra,  and  vagina  (Hart) : 
V,  U,  urethra ;  B,  B,  bladder. 


sometimes,  however,  the  empty  organ  is  strongly  contracted,  the  cavity  of  the 
bladder  then  presenting  a  slit-like  lumen.  Maximum  distention  carries  the 
bladder,  together  with  the  peritoneum,  well  above  the  pubes,  with  the  conse- 
quent tendency  to  backward  displacement  of  the  uterine  fundus. 

The  Female  Ureter. — The  ureter  ir  the  female  (Pis.  7,  8)  presents  peculiar- 
ities in  its  relations  within  the  pelvis  that  deserve  notice.  After  the  usual 
relations  of  the  abdominal  portion  of  its  course — proceeding  downward  and 
inward  upon  the  psoas  muscle  and  its  fascia,  being  crossed  by  the  ovarian  ves- 
sels, and  crossing  the  iliac  vessels  about  1.5  centimeters  below  the  division  of 
the  common  iliac  artery — the  ureter  passes  into  the  true  pelvis  in  front  of  the 
sacro-iliac  synchondrosis,  thence  upon  the  obturator  internus  muscle  and  its 
fascia  toward  its  termination,  running  beneath  the  root  of  the  broad  ligament. 

About  opposite  the  origin  of  the  vesical   and  uterine  arteries  from   the 


42  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

internal  iliac,  the  ureter  forms  a  sweeping  curve  which  is  most  pronounced 
where  the  uterine  artery  crosses  the  ureter,  about  on  a  level  with  the  os  exter- 
num. The  ureter  crosses  the  uterus  at  a  point  closely  corresponding  with 
the  position  of  flexure  of  the  uterine  body  upon  the  cervix,  here  lying  between 
the  vesical  venous  plexus  laterally  and  the  utero-vaginal  venous  plexus  and 
the  uterine  artery  internally. 

The  lower  part  of  the  ureter  passes  at  first  at  the  side  of  the  upper  third 
of  the  vagina ;  it  then  reaches  the  vesico-vaginal  septum,  within  which  it  lies 
for  1.5  to  2  centimeters  before  entering  the  bladder-wall. 

The  ureter  does  not  extend  lower  than  about  the  middle  of  the  anterior 
wall  of  the  vagina ;  as  it  rests  directly  upon  the  latter,  it  is  enclosed  for  a 


Pi 

'Oinoiitory. 

Ovario 

ligan 

-peh 

lent. 

>ic 

—Tube. 

-- 

—Ova> 

y. 

~~ 

B 

road  liga 

Pt, 

ft?* 

^Retropubic 
triangle. 


%    v  v 


;  j  j  i  X    \! 

i  I  Internal  sphincter  ani.  ^"-i 


Clitoris. 


Bulbo-cavernosus. 
'External  sphincter. 


1        i 
iLevbtor.'i 


Fig.  22.— Mesial  section,  showing  the  relation  of  the  viscera  in  their  normal  position  (Dickinson). 

short  distance  (about  1  centimeter)  within  a  distinct  fibrous  sheath  continuous 
with  the  bladder-wall  (Waldeyer). 

The  course  of  the  ureter  within  the  vesical  wall  is  obliquely  downward 
and  inward  for  a  distance  of  about  1.5  centimeters.  The  lower  part  of  the 
tube,  from  its  investment  by  the  above-mentioned  sheath  to  its  termination,  is 
cylindrical  in  form,  in  contrast  with  the  remaining  flattened  portions  of  the 
canal. 

2.  Intermediate  Organ. — The  Vagina. — The  musculo-membranous  canal 
of  the  vagina  forms  the  intermediate  tract  connecting  the   internal  and  the 


GENERATIVE  ORGANS. 


Blood-vessels  of  the  pelvis  (Boursrery  and  Jacob) :  the  anterior  part  of  the  pelvis  has  been  removed,  and 
the  bladder  and  the  anterior  vaginal  wall  have  been  partially  cut  away.  The  uterus  is  drawn  up  and  the 
Fallopian  tubes  are  displaced  into  the  iliac  fossse. 


GENERATIVE  ORGANS. 


Plate  8. 


Pelvic  organs  in  situ  of  a  young  woman  of  sixteen  years  ;  seen  from  above  after  careful  removal  of  the 
intestines  without  dislurhimr' the  relations  :  .1,  abdominal  aorta;  17',  inferior  vena  cava  .  If,  psoas  mni-'ii  s: 
/V,  promontory  of  sacrum:  J:,  cut  rectum;  1>,  pouch  of  Douglas;  BV,  body  of  uterus;  I- 1,  fundus  ,  it  "ens 
111,  bladder:  (>,  ovary;  T,  Fallopian  tube;  BL,  round  ligament;  Ur,  ureter:  OA,  ovarian  artery  (redrawn 
from  Waldeyer). 


ANATOMY    OF    THE    GENERATIVE    ORGANS. 


43 


external  organs  of  generation.  Piercing  the  pelvic  floor  with  its  lower  end,  it  lies 
chiefly  within  the  cavity  of  the  pelvis,  in  relation  with  the  bladder  and  the  urethra 
in  front  and  with  the  rectum  behind,  the  vesico-vaginal  and  the  recto-vaginal 
septa  intervening.  The  axis  of  the  vagina  (Fig.  23),  while  corresponding  in 
general  with  that  of  tbe  pelvic  cavity,  resembles  that  of  the  urethra  and  the 
rectum  in  presenting  a  double  or  S-like  curvature.  The  axis  of  the  lower  third 
of  the  vagina  corresponds  closely  with  the  plane  of  the  pelvic  brim  ;  that  of  the 
upper  two-thirds  lies  parallel  with  the  axis  of  the  lower  third  of  the  rectum, 
forming  almost  a  right  angle  to  the  axis  of  the  anal  extremity  of  the  gut. 
The  two  principal  vaginal  walls,  the  anterior  and  the  posterior,  ordinarily 
lie  in   contact  except  at   the  sides,  where   the  lumen  of  the  canal  laterally 


Fig.  23.— Sagittal  section  of  female  pelvis,  showing  axis  of  the  vagina. 


expands.  In  cross-section,  therefore,  the  vaginal  passage  under  normal  con- 
ditions appears  H-shaped  (Fig.  24) ;  when  distended  it  is  club-shaped,  being 
more  capacious  above  than  below,  where  the  entrance  marks  the  least  diameter. 
The  shorter  anterior  ivall  (Fig.  25)  extends  from  the  vaginal  entrance  to 
the  apex  of  the  corresponding  utero-vaginal  recess  or  anterior  fornix,  and 
measures  about  6.5  centimeters,  or  about  1\  inches;  seen  from  behind,  this 
surface  appears  triangular  in  its  general  form,  the  base  being  above,  corre- 
sponding with  the  greater  superior  diameter  of  the  canal.  The  anterior  wall 
is  very  conspicuously  marked  by  transverse  rugae  (Fig.  26),  which  are  especially 
prominent  in  the  virgin ;  an  additional  vertical  fold,  the  anterior  column,  is 


44 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


Ua 


present  at  the  lower  part  of  the  passage,  where,   also,  this  wall,  distinctly 

thicker  than  its  fellow,  is  most  robust. 

The  posterior  wall,  much  the  longer,  extends  from  the  vaginal  orifice  or 

the  hymen  to  the  apex  of  the  deep  posterior  fornix  (Fig.  25)  or  retro-cervical 

fossa ;  it  lies  in  front  of  the  anterior  rectal 
wall,  with  which,  throughout  its  lower 
two-thirds,  it  is  united  by  areolar  tissue. 
The  posterior  wall  measures  about  9  cen- 
timeters, or  about  3-J-  inches,  in  length, 
being  broader  above  than  below  ;  its  supe- 
rior third  receives  an  imperfect  covering 
of  the  peritoneum  which  forms  the  most 
dependent  portion  of  the  anterior  wall  of 
Douglas's  pouch.  While  distinctly  less 
corrugated  than  the  anterior  wall,  the  pos- 


Fig.  24. — Section  illustrating  the  characteristic 
form  of  the  vaginal  cleft  (Henle) :  Ua,  urethra  ■ 
Va,  vagina  ;  L,  levator  ani ;  It,  rectum. 


Fig.  25.— Sagittal  section,  showing  vaginal  walls 
ami  relation  of  cervix  uteri  (Skene). 


terior  surface  in  the  virgin  possesses  numerous  transversely  disposed  rugse  as 


Fig.  26.— Sagittal  section  of  vagina  of  a  virgin, 
showing  rugous  condition  of  walls  and  enlarged 
upper  extremity  (Hart). 


Fig.  27.— Sagittal  section  of  vagina  of  a  multipara, 
one-half  natural  size  (Hart). 


well  as  a  vertical,  and  sometimes  double,  posterior  column.    Subsequent  to  the 
dilatation  incident  to  parturition  the  vaginal  rugse  are  much  less  conspicuous 


ANATOMY   OF   THE   GENERATIVE    ORGANS.  45 

(Fig.  27),  those  on  the  posterior  wall  often  almost  entirely  disappearing,  leav- 
ing the  somewhat  pouched  surface  relatively  smooth ;  the  folds  of  the  anterior 
wall  are  retained  to  a  much  greater  extent. 

In  structure  the  walls  of  the  vagina  consist  of  a  mucous  membrane,  a  mus- 
cular coat,  and  a  fibrous  tunic.  The  mucosa  is  covered  by  a  thick  stratified, 
squamous  epithelium,  and  possesses  numerous  papillae.  The  rugse  include 
within  their  structure  not  only  the  tissues  of  the  mucosa,  but  also  bundles  of 
involuntary  muscle  and  large  veins.  True  glands,  if  found  at  all,  are  repre- 
sented by  a  few  sparingly  distributed  tubular  structures  within  the  upper  part 
of  the  vaginal  mucous  membrane,  the  acid  secretion  which  bathes  its  surface 
being  the  product  of  the  general  mucosa.  The  deepest  part  of  the  mucous  mem- 
brane, that  corresponds  with  the  submucous  layer,  is  succeeded  by  the  mus- 
cular coat,  composed  of  an  inner  circular  and  an  outer  longitudinal  stratum 
of  unstriped  muscle. 

The  fibrous  tunic  consists  of  a  dense  coat,  rich  in  fibro-elastic  tissue,  which 
is  derived  as  a  prolongation  of  the  recto-vesical  fascia  and  materially  con- 
tributes to  the  strength  of  the  vaginal  wall.  The  lower  extremity  of  the 
canal  is  encircled  by  a  thin  plane  of  muscular  fibres  constituting  the  con- 
strictor vaginse  muscle,  and  is  closely  attached  to  additional  bands  derived 
from  the  levator  ani. 

Blood-vessels  and  Nerves. — The  vascular  and  nervous  supplies  of  the  vagina 
are  very  generous.  The  arteries  are  derived  from  the  vaginal,  the  internal 
pudic,  the  vesical,  and  the  uterine  branches  of  the  internal  iliac.  Correspond- 
ing veins  return  the  blood  to  a  large  extent,  in  addition  to  which  the  vaginal 
plexus  surrounds  the  lower  part  of  the  canal  and  communicates  freely  with 
the  neighboring  vesical  and  hemorrhoidal  plexuses.  The  urethral  plexus 
around  the  upper  portion  of  the  urethral  canal  receives  the  dorsal  veins  of  the 
clitoris.  Within  the  submucosa  large  and  plentiful  venous  radicles,  together 
with  bands  of  involuntary  muscle,  give  this  layer  the  character  of  erectile  tissue. 

The  lymphatics  of  the  vagina  constitute  two  groups,  those  from  the  lower 
and  the  upper  portions  of  the  caual.  The  former  join  the  lymphatics  of  the 
external  genital  organs  and  end  within  the  superior  or  oblique  set  of  inguinal 
glands ;  the  latter,  together  with  the  vessels  from  the  lower  part  of  the  uterine 
body  and  the  cervix,  proceed  outward  within  the  broad  ligament,  joining  with 
the  lymphatics  from  the  oviduct  and  the  ovaries,  and  terminate  in  the  lumbar 
glands. 

The  nerves  of  the  vagina  are  contributions  from  both  the  sympathetic  and 
the  cerebro-spinal  system.  The  branches  of  the  former  are  derived  from  the  infe- 
rior hypogastric  plexus,  those  of  the  latter  from  the  fourth  sacral  and  the  pudic 
nerve.     The  sympathetic  fibres  are  largely  distributed  to  the  vascular  tissues. 

3.  Internal  Organs  of  Generation. — The  Uterus. — The  uterus,  the  thick- 
ened and  specialized  segment  of  the  generative  tube  for  the  reception,  the  reten- 
tion, the  development,  and  the  final  expulsion  of  the  product  of  conception,  in 
its  mature  but  virgin  condition  is  a  slightly  pyriform  body  whose  thick,  dense 
walls  enclose  a  narrow,  cleft-like  cavity.     The  organ  lies  within  the  pelvis, 


46 


AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 


held  by  supporting  peritoneal  folds  and  muscular  bands  extending  between  the 
bladder  in  front,  the  rectum  and  the  sacrum  behind,  and  the  pelvic  walls  at 
the  sides ;  the  most  dependent  portion  of  its  lower  and  smaller  segment,  the 
cervix,  projects  within  the  upper  part  of  the  vagina. 

The  virgin  uterus  (Figs.  28,  29)  measures  about  7.5  centimeters  (about  3 
inches)  in  length,  4  centimeters  (about  1J  inches)  in  its  greatest  width,  and 


Fig.  2S. — Anterior  view  of  virgin  uterus,  show- 
ing relations  of  cervix  to  corpus  uteri  and  reflec- 
tion of  peritoneum  at  isthmus. 


Flu.  29.— Sagittal  section  of  virgin  uterus,  show- 
ing position  of  os  internum,  fusiform  character  of 
the  cervical  canal,  and  relations  of  the  peritoneum. 


about  2.5  centimeters  (1  inch)  in  thickness ;  of  the  entire  organ,  approxi- 
mately three-fifths  belong  to  the  body  and  two-fifths  to  the  neck,  the  latter 
being  relatively  much  longer  in  the  nulliparous  adult  than  after  pregnancy  has 


^^     VflCINA 


<^ 


^  Portion 
Portion, 


Fig.  SO.— Diagram  illustrating  the  relations  of  the  uterus  to  the  vagina,  bladder,  and  peritoneum. 

occurred.  The  division  of  the  uterus  into  body  and  neck  is  indicated  exter- 
nally by  the  constricted  isthmus  uteri,  which  is  situated  about  midway  in  the 
organ  ;  internally,  however,  this  boundary  is  uncertain,  since  the  contours  of 
the  cervical  mucous  membrane  gradually  pass  into  those  of  the  general  uterine 
linino-. 


A  FA  TO  MY    OF    THE    GENERATIVE    ORGANS. 


17 


The  pyriform  body  is  almost  flat  on  its  anterior  surface,  but  posteriorly  is 
distinctly  convex  ;  its  superior  and  anterior  arched  border  is  thick  and  rounded, 
and  passes  over  into  the  slightly  convex  lateral  borders  at  the  superior  angles. 
The  upper  part  of  the  organ,  including  its  superior  arched  border,  constitutes 
the  fundus  and  is  completely  invested  with  peritoneum.  The  serous  covering  of 
the  anterior  surface  extends  only  as  far  as  the  isthmus,  whence  it  is  reflected  to  the 
neighboring  vesical  wall.  The  peritoneum  on  the  posterior  wall  is  complete, 
since  the  serous  membrane  is  prolonged  downward  and  backward  about  2.5  cen- 
timeters beyond  the  cervix  upon  the  posterior  wall  of  the  vagina  before  passing 
to  the  rectum.    The  lateral  borders  mark  the  attachment  of  the  broad  ligaments. 

The  cervix,  slightly  spindle-form  in  general  outline,  may  be  divided  into 
three  portions  or  zones  (Fig.  30),  the  supravaginal,  the  intermediate,  and  the 
intravaginal.  The  first  of  these  zones  occupies  the  upper  half  of  the  cervix, 
extending  somewhat  farther  forward  along  the  anterior  surface,  where  it  comes 
in  relation  with  the  bladder,  than  posteriorly,  where  covered  by  the  peritoneum 
of  Douglas's  pouch.  The  intermediate  portion  includes  the  zone  of  vaginal 
attachment,  hence  it  is  narrow  and  oblique,  extending  higher  behind  than  in 
front.  The  intravaginal  segment,  or  os  ideri,  projects  within  the  vaginal  canal 
in  such  manner  that  its  axis  is  directed   toward  the  posterior  wall,  and  it 


Fundus  split  open. 


Fig.  31.— Cavity  of  uteri: 

anterior 


d  by  removal  of 


nii-'ims  rendition  ,,l'  die  cervi 


presents  the  transversely  oval  orifice  of  the  cervical  cavity,  bounded  by  the 
rounded  and  prominent  anterior  and  posterior  lips  or  labia,  the  anterior  of 
which  is  somewhat  the  thicker  and  shorter.  The  proportion  between  the  body 
and  the  cervix  varies  with  age :  in  the  young  virgin  adult  the  uterus  is  about 
equally  divided  between  these  segments ;  in  early  life  the  cervix  greatly  pre- 
ponderates over  the  imperfectly  developed  fundus  ;  while  after  childbirth  the 
fundus  never  returns  to  its  former  size,  always  remaining  enlarged  and  nearly 
twice  its  original  length  (Fig.  31).  With  the  advent  of  old  "age  the  entire 
organ  suffers  marked  atrophy. 


48  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

The  cavity  of  the  virgin  uterus  is  very  narrow,  the  apposition  of  the 
anterior  and  posterior  walls  of  its  body  reducing  the  space  to  little  more  than 
a  longitudinal  cleft,  as  seen  in  mesial    sagittal  sections  (Fig.  29).     Viewed 


Fig.  33. — Casts  of  the  cavities  of  uteri  of  various  ages  and  conditions  (modified  from  Hagemann) : 
2,  3,  from  nullipara;  of  eighteen  and  twenty-four  years  ;  4.  from  a  woman  of  forty-eight  years  who  had 
one  child  fifteen  years  previous. 

from  in  front,  the  uterine  cavity  is  triangular,  the  expanded  base  extending  be- 
tween the  orifices  of  the  oviducts,  and  the  apex  corresponding  with  the  inner 


Fig.  35.— Front  and  pro- 
file views  of  casts  of  the 
Fig.  :U.— Casts  of  the  cavities  of  uteri  from  (5)  a  nullipara  of  sixty-       uterine  cavity  of  a  new- 
eight  years,  and  (6)  from  a  parous  subject  of  seventy  years  (modified  from        born  infant  (modified  from 
Hagemann).  Hagemann). 

opening  of  the  cervical  canal.     On  account  of  the  encroachment  of  the  uterine 
walls,  the  cavity  of  the  uterus  between  the  angles  presents  concave  outlines. 

The  cavity  of  the  cervix  is  fusiform,  being  of  larger  diameter  at  its  middle 
than  at  the  ends,  the  os  internum  and  the  os  externum.  The  os  internum,  which 
marks  the  point  of  greatest  contraction,  possesses  a  lumen  of  circular  outline:  the 


ANATOMY   OF    THE    GENERATIVE    ORGANS. 


49 


os  externum  before  pregnancy  appears  as  a  narrow,  transversely  placed  orifice. 
The  anterior  and  posterior  walls  of  the  virgin  cervical  canal  exhibit  conspic- 
uous plications  depending  upon  the  arrangement  of  the  bundles  of  muscular 
tissue  ;  these  ruga?  are  arranged  as  principal  longitudinal  folds,  the  anterior  and 
posterior  columns,  from  which  secondary  plications  extend  laterally.  These 
corrugations  collectively  form  the  arbor  vitce  (Fig.  35)  of  the  uterus,  being  best 
marked  in  the  virgin  and  being  effaced  by  repeated  parturitions. 

Structure. — The  uterine  walls  include  a  mucous,  a  muscular,  and  a  serous 
coat.  The  mucosa  consists  of  a  tunica  propria  of  delicate  bundles  of  fibro- 
elastic  tissues  covered  by  an  epithelium  composed  of  a  single  layer  of  ciliated 
columnar  cells.  Numerous  wavy  tubular  depressions,  the  uterine  glands  (Fig. 
36),  are  also  lined  by  the  ciliated   epithelium.     Since  a  submucous  layer  is 


Fig.  36.— Section  of  human  uterus,  including  mucosa  (a)  and  adjacent  muscular  tissue  (6) ;  c,  epithe- 
lium of  free  surface  and  tubular  uterine  glands  (d) ;  /,  deepest  layer  of  mucosa,  containing  fundi  of 
glands ;  h,  strands  of  non-striped  muscle  penetrating  within  the  mucosa  (Piersol). 

wanting,  the  blind  and  often  forked  extremities  of  these  glands  abut  directly 
upon  the  muscular  tissues. 

The  cervical  mucosa  differs  from  that  of  the  body,  being  thicker  and  firmer, 
supplied  with  papillae,  and  covered  with  stratified  squamous  epithelium  within 
the  lower  third.  In  the  upper  half  or  two-thirds  of  the  cervix  the  epithelium 
is  ciliated  columnar,  similar  to  that  of  the  body.  In  addition  to  the  tubular 
follicles,  the  representatives  of  the  usual  uterine  glands,  numerous  short,  widely- 
expanded  mucous  crypts  lie  within  the  cervical  mucosa.  Retention  of  the 
secretion  of  some  of  these  mucous  sacs  often  takes  place,  the  resulting  greatly 
distended  cysts  appearing  as  translucent  yellowish  vesicles,  the  so-called  ovulce 
Nabothi.  In  its  meagre  supply  of  glands  the  mucous  membrane  of  the  lower 
part  of  the  cervix  still  further  resembles  that  of  the  adjacent  vaginal  surface. 

The  muscular  coat  (Fig.  37)  of  the  uterus  consists  of  bundles  of  unstriped 
muscle  (Fig.  38)  separated  by  bands  of  connective  tissue  and  surrounding  vas- 
cular channels.    Although  irregularly  arranged,  the  muscular  tissue  is  disposed 


50 


AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 


in  three  general  strata — an  inner,  a  middle,  and  an  outer  layer.     The  inner  layer, 

88© 


Fig.  37. — Arrangement  of  uterine  muscle,  as  seen  from  in  front  after  removal  of  serous  coat  (He'lie). 

composed  principally  of  longitudinal  bundles,  is  in  direct  contact  with  the  mu- 


Fig.  38.— A,  isolated  muscle-elements  of  the  non-pregnant  uterus ;  B,  cells  from  the  organ  shortly  after 
delivery  (Sappey). 

cosa,  and  is  sometimes  regarded  as  belonging  to  that  layer,  as  being  a  hypertrophied 


ANATOMY   OF    THE    GENERATIVE    ORGANS. 


51 


muscularis  mucosae.  The  middle  layer  is  most  robust,  and  forms  the  greater 
part  of  the  muscular  coat,  consisting  chiefly  of  bundles  having  a  general  circu- 
lar disposition.  This  layer  is  also  distinguished  by  the  numerous  large  venous 
channels  enclosed  between  its  bundles,  hence  the  name,  stratum  vasculare.  The 
outer  layer  includes  both  circular  and  longitudinal  bundles,  the  latter  predomi- 
nating and  lying  in  close  relation  with  the  superimposed  serous  coat.  Many 
bundles  of  the  outer  layer  pass  into  the  broad  ligaments  ;  some  of  these  enter 
the  round  ligaments  and  accompany  the  areolar  tissue  and  the  blood-vessels 
composing  these  structures  toward  the  groin,  while  others  extend  along  the 
oviducts  and  ovarian  ligaments.  Muscular  bands  pass  also  from  the  uterus 
into  its  supporting  folds,  the  sacro-uterine  band  being  particularly  robust.  The 
musculature  of  the  cervix  is  distinguished  by  greater  regularity  in  its  arrange- 


Fig.  39. — Broad  ligaments  viewed  from  the  posterior  surface,  showing  uterus,  oviducts,  and  ovaries  ; 
the  natural  position  of  the  latter  has  heen  disturbed  in  consequence  of  the  separation  of  the  supporting 

attachments. 


ment,  which  includes  a  distinct  inner  longitudinal,  a  middle  circular,  and  an 
outer  longitudinal  layer. 

The  serous  coat  of  the  uterus  comprises  the  usual  constituents  of  the 
peritoneum. 

Ligamenis. — The  supporting  apparatus  of  the  uterus  consists  of  two  parts, 
the  folds  of  peritoneum  and  the  muscular  bands  which  extend  from  the  uterus 
to  adjacent  structures.  The  first  group  includes  two  anterior,  two  lateral,  and 
two  posterior  ligaments  ;  the  second  group,  the  so-called  "  muscular  ligaments," 
is  represented  by  the  utero-inguinal,  the  utero-ovarian,  the  utero-pelvic,  and 
the  utero-sacral  muscular  bands;  the  last  of  these,  the  utero-sacral,  are  included 
within  the  posterior  peritoneal  folds ;  the  remaining  ones  lie  between  the  layers 
of  the  lateral  or  broad  lio-aments. 


52  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

The  anterior  ligaments  are  two  inconspicuous  semilunar  peritonea]  folds  which 
pass  between  the  upper  part  of  the  cervix  on  each  side  to  the  adjacent  posterior 
surface  of  the  bladder,  and  bound  the  vesico-uterine  pouch. 

The  lateral  or  broad  ligaments  (Fig.  39),  as  implied  by  their  name,  are  two 
wide  duplicatures  of  peritoneum  that  extend  from  the  sides  of  the  uterus  and 
the  vagina  to  be  attached  to  the  lateral  wall  and  the  floor  of  the  pelvis.  Each 
of  these  broad  folds  presents  four  borders,  the  superior,  the  inferior,  the  inter- 
nal, and  the  external ;  of  these  but  one,  the  superior,  is  free,  the  others  being 
intimately  joined  with  neighboring  parts.  The  superior  or  free  border  encloses 
the  oviduct,  whose  tortuous  course  it  follows  as  far  as  the  fimbriated  end ;  at 
this  point  the  plication  diverges  toward  the  pelvic  wall  and  forms  the  infun- 
dibulo-pelvic  ligament,  which  fold  connects  the  end  of  the  tube  with  the  side  of 
the  pelvis  and  transmits  the  ovarian  vessels.  The  inferior  border  is  united 
with  the  recto-vesical  fascia  covering  the  levator  ani,  the  subperitoneal  tissue 
intervening  between  its  diverging  lamella?  giving  transit  to  blood-vessels  and 
nerves  as  well  as  to  the  ureter.  The  internal  border  is  attached  to  the  sides 
of  the  uterus  and  the  vagina,  the  blood-vessels  and  muscular  bands  passing 
into  the  tissue  of  the  broad  ligament  between  its  divergent  layers.  The  external 
border  comes  in  relation  with  the  obturator  fascia  and  affords  transit  for  the 
uterine  vessels  and  the  round  ligament. 

The  broad  ligaments  enclose  within  their  serous  folds  structures  of  import- 
ance (Fig.  40).     Along  their  unattached  superior  margins  lie  the  oviducts;  a 


Fig.  40.— Diagrammatic  section  of  broad  ligament,  showing  relations  of  the  contained  structures. 

little  lower  and  anteriorly  are  situated  the  round  ligaments ;  posteriorly,  the 
ovaries  and  their  muscular  attachments ;  numerous  blood-vessels,  nerves,  and 
lymphatics,  together  with  the  parovarium,  the  paroophoron,  and  the  utero-pel- 
vic  bundles  of  involuntary  muscles  which  pass  from  the  uterus  and  the  vagina 
to  the  obturator  fascia,  are  additional  structures  included  within  these  folds. 

The  round  ligaments  (Fig.  41)  are  two  flattened  cord-like  bands,  from  10  to  12 
centimeters  in  length,  attached  to  the  upper  segment  of  the  uterus  in  front  of 
the  oviducts,  and  extending  from  this  point  downward,  outward,  and  forward, 
winding  round  the  deep  epigastric  artery  on  the  inner  side  of  the  external  iliac 
artery,  to  the  internal  orifices  of  the  inguinal  canals,  through  which  they  pass 


ANATOMY   OF   THE    GENERATIVE    ORGANS. 


53 


to  blend  with  the  tissues  of  the  labia  rnajora.     The  round  ligament  possesses  a 
covering  of  peritoneum,  and  in  the  young  subject  a  funnel-like  depression  marks 


Fig.  41. — Dissection  of  the  pelvic  organs,  showing  the  relation  of  the  abdominal  parietes  to  the  round  liga- 
ments and  the  bladder  :  1, 3,  the  obliterated  hypogastric  arteries  ;  2,  the  urachus  (Bourgery  and  Jacob). 

a  tubular  extension  of  the  peritoneal  sac  along  the  cord  as  it  leaves  the  abdomen  ; 
this  extension  constitutes  the  canal  of  Nuch,  and  is  homologous  with  the  pro- 


Fig.  42.— Posterior  view  of  the  uterus  and  ovaries,  with  the  peritoneal  folds  composing  the  broad  liga- 
ments and  the  utero-rectal  fossa  (modified  from  Hodge). 

cessus  vaginalis  of  the  male.     It  is  usually  obliterated  after  early  life,  but  may 
persist,  and,  in  rare  cases,  be  accompanied  by  an  abnormally  descended  ovary, 


54 


AMERICAN    TEXT- BO  OK    OF    OBSTETRICS. 


which  then  occupies  a  position  within  the  labia,  behind  the  peritoneal  sac.  In 
structure  the  round  ligament  consists  of  bundles  of  connective  tissue  and  blood- 
vessels, together  with  plain  muscular  tissue  derived  from  the  uterus. 

The  posterior  or  recto-uterine  ligaments  are  two  peritoneal  folds  which  pass 
backward  from  the  cervix  and  the  upper  part  of  the  vagina  to  become  con- 
tinuous with  the  serous  covering  of  the  second  portion  of  the  rectum.  The 
deep  fossa  included  between  these  folds  laterally,  the  uterus  anteriorly,  and 
the  rectum  posteriorly  constitutes  the  pouch  of  Douglas  (Fig.  42),  which  is  fre- 
quently occupied  by  coils  of  small  intestine.  Between  the  layers  of  the  posterior 
ligaments  flat  bands  of  involuntary  muscular  tissue,  the  so-called  utero-sacral 


Fig.  43. — Sagittal  section  of  female  pelvis,  showing  the  utero-sacral  ligaments  suspending  the  uterus,  also 
the  pubic  segment  part  of  tne  supporting  apparatus  of  the  uterus  (Dickinson). 

ligaments  (Fig.  43),  extend  on  each  side  from  the  highest  segment  of  the  cervix 
to  the  sides  of  the  sacrum,  at  the  level  of  the  sacro-iliac  juncture.  These  bands, 
among  the  most  important  parts  of  the  supporting  apparatus  of  the  uterus,  are 
intimately  related  with  the  muscular  coat  of  the  rectum,  which  tube  they 
encircle  near  the  union  of  its  first  and  second  parts ;  laterally  and  anteriorly 
they  are  in  close  relation  with  the  pouch  of  Douglas. 

The  position  of  the  normal  uterus  (Fig.  22)  during  life  has  received  considera- 
tion from  many  investigators,  whose  conclusions,  however,  have  been  so  contra- 
dictory and  uncertain  that  almost  every  situation  of  the  organ  has  in  turn  been^ 
regarded  as  representing  its  normal  relation.  This  discrepancy  has  been  due 
in  large  measure  to  the  methods  of  examination  employed,  which  include 
observations  on  the  cadaver,  bimanual  examination  of  the  pelvic  organs  of  the 
living  subject,  and  frozen  sections  of  the  parts  shortly  after  death. 

The  examination  of  the  viscera  in  the  cadaver  in  the  usual  way,  even 
when  carried  out  with  skill  and  precaution,  must  necessarily  be  untrustworthy 


ANATOMY   OF   THE    GENERATIVE   ORGANS. 


55 


as  to  the  details  of  topographical  relations,  on  account  of  the  uncertainty  in- 
troduced by  reason  of  the  unavoidable  post-mortem  alterations  and  inevitable 
distortions  affecting  the  organs.  The  apparent  exactness  of  the  method  of 
frozen  sections  likewise  is  unfavorably 
influenced  by  the  relaxation  after  death 
of  the  supporting  bands  which  during 
life  maintain  the  positions  of  the  organs  ; 
it  follows,  therefore,  that  the  testimony 
of  sections  cannot  be  accepted  as  unim- 
peachable evidence  as  to  relations  during 
life,  since  the  relations  preserved  are 
only  those  existing  at  the  time  of  fix- 
ation ;  likewise,  the  possibility  of  en- 
countering the  effects  of  pathological 
changes  in  frozen  sections  must  also 
be  appreciated.  The  testimony  of  the 
most  competent  and  careful  investiga- 
tors points  to  the  conclusion  that  the 
most  valuable  and  trustworthy  observa- 
tions as  to  the  normal  position  of  the 
uterus  are  to  be  gathered  from  careful  examinations  of  properly  preserved 
bodies,  where  the  organs  have  been  hardened  in  situ  immediately  after  death. 
The  results  of  such  investigations  closely  agree  with  the  opinions  of  the  most 
expert  observers  derived  from  repeated  examinations  on  the  living  subject. 


Fig.  44. — Diagrams  illustrating  range  of  va- 
riation in  position  of  uterus  as  affected  by  dis- 
tention of  the  bladder  (Van  de  Warier). 


-Longitudinal  section  of  Fallopian  tube,  exposing  the  complicated  longitudinal  plications  of 
the  mucosa  which  expand  into  the  fimbria;  ISappey). 


In  accordance  with  the  conclusions  based  on  such  grounds,  the  normal  uterus 
most  probably  occupies  a  position  almost  horizontal  in  the  upright  posture : 
the  fundus,  usually  slightly  to  one  side  of  the  mid-line,  rests  on  the  bladder 
and  is  directed  forward  and  upward,  while  the  cervix  forms  a  slight  deflection 
with  the  axis  of  the  uterine  body  and  looks  down  and  backward  against  the 


56  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

posterior  vaginal  wall.  Whether  the  uterus  lies  most  frequently  to  the  right 
or  to  the  left  of  the  mid-line  is  still  in  dispute ;  the  latter  position,  to  the 
right,  is  probably  most  usually  encountered  (His),  although  the  opposite  con- 
dition, as  shown  on  Plate  8,  is  certainly  not  uncommon.  The  topographical 
relations  between  the  uterus  and  the  bladder  are  so  close  that  the  position  of 
the  womb  is  materially  influenced  by  vesical  distention.  The  range  of  varia- 
tion in  the  position  of  the  normal  uterus  is  diagrammatically  represented  by 
Figure  44. 

The  oviducts,  or  Fallopian  tubes  (Fig.  38),  the  representatives  of  the  un- 
united portions  of  the  fetal  Mullerian  ducts,  extend  from  the  superior  rounded 
angles  of  the  uterus,  within  and  along  the  free  upper  margin  of  the  broad 
ligaments  for  a  distance  of  from  10  to  12  centimeters,  to  the  vicinity  of  the 
ovaries,  where  each  terminates  in  an  expanded  funnel-shaped  orifice,  the  pavil- 
ion or  infundibulum,  surrounded  by  a  series  of  fringed  processes,  the  fimbriae 
(Fig.  45).  Examined  in  carefully-preserved  specimens  retaining  the  typical 
position  of  parts,  the  tube  at  first  passes  outward  closely  related  with  the  pelvic 
floor ;  it  then  turns  upward  along  the  attached  anterior  border  of  the  ovary, 
when,  after  reaching  the  upper  pole  of  the  gland,  the  tube  bends  downward 
upon  the  free  posterior  border  and  the  inner  surface  of  the  ovary  (Figs.  22, 
41),  which  are  by  this  means  partly  masked  (Waldeyer). 

The  oviduct  commences  at  the  inner  attached  extremity  as  a  narrow 
tube,  the  isthmus,  about  2  millimeters  in  diameter;  during  its  further  slightly 

wavy  course  it  gradually  gains  in 
width  until  the  tube  measures  4 
millimeters  or  more,  when  it 
again  becomes  somewhat  nar- 
rowed, but  beyond  the  ovary  it 
rapidly  expands  into  the  ampullas 
and  the  fimbriated  extremity  (Fig. 
46).  The  lumen  of  the  tube  is 
narrowest  at  its  inner  end,  where 
it  opens  into  the  cavity  of  the 
t" uterus    by    a    minute   orifice,  the 

Fig.  46.-Portion  of  broad  ligament  stretched  to  show      osfmm    internum,    which    Scarcely 

the  parovarium  (P)  lyim;  between  the  folds  and  consisting  ...  , 

of  the  head-tube  and  cross-tubules  (Gegenbaur).  admits  a  bristle  ;  the  diameter  of 

the  canal  gradually  increases  until 
it  presents,  just  before  its  final  expansion  into  the  fimbriated  orifice,  a  distinct 
opening,  the  ostium  abdominale  (from  4  to  6  millimeters  in  width),  situated  at 
the  bottom  of  the  cleft-like  depression  leading  from  the  attached  border  of 
the  fimbriated  expansion. 

Structure. — The  oviduct  consists  of  three  coats — an  inner  mucous,  a  middle 
muscular,  and  an  outer  serous.  The  mucous  lining  presents  numerous  longi- 
tudinal folds  (Fig.  47) ;  these  become  more  conspicuous  within  the  infundibu- 
lum, where  they  greatly  increase  in  size  and  complexity  and  terminate  in  the 
sinuous  border  of  the  fimbriae.     All  parts  of  the  canal,  including  its  expanded 


ANATOMY    OF   THE    GENERATIVE    ORGANS. 


57 


outer  end,  are  clothed  by  a  single  layer  of  ciliated  columnar  cells,  whose  ciliary 
current  sweeps  from  the  fimbria?  toward  the  uterine  end  of  the  tube.  At  the  free 
edge  of  the  fimbriae  the  columnar  epithelial  cells  give  place  to  the  low,  plate- 
like elements  of  the  peritoneum  covering  the  exterior  of  the  tube.  Glands 
are  absent  within  the  mucous  membrane  of  the  oviduct.  The  muscular  tunic 
includes  a  principal  inner  layer  of  circularly-disposed  bundles  of  involuntary 
muscle  and  a  slightly-developed  outer  layer  of  longitudinal    bundles.     The 


Fig.  47.— Transverse  section  of  Fallopian  tube,  showing  the  complicated  arrangement  of  the  longitudinal 
plications  which  are  here  cut  across  (Martin). 

serous  coat  consists  of  the  fibro-elastic  stroma  and  endothelium  of  the  general 
peritoneal  investment  contributed  by  the  broad  ligament. 

The  blood-vessels  of  the  oviducts  are  branches  from  the  ovarian  and  the 
uterine  arteries  and  the  corresponding  veins,  the  arteries  possessing  an  unusu- 
ally tortuous  course.  The  nerves  are  derived  from  the  ovarian  and  uterine 
plexuses,  and  consist  of  both  medullated  and  pale  fibres. 

The  Ovaries.  —  Each  ovary  presents  a  flattened  ovoid  mass,  somewhat 
almond-shaped,  which  appears  as  an  appendage  of  the  posterior  surface  of  the 
broad  ligament  (Fig.  39),  to  which  the  organ  is  attached  by  its  straighter  anterior 
border.  The  dimensions  vary  with  the  individual  as  well  as  with  the  condi- 
tion of  functional  activity ;  the  longest  diameter  usually  measures  about  3.5 
centimeters,  the  width  about  2  centimeters,  and  the  thickness  a  little  over  1 
centimeter.  The  weight  of  the  ovary  is  ordinarily  between  6  and  7  grams, 
the  right  being  commonly  slightly  heavier  and   larger  than  the  left  ovary. 

The  anterior  border  alone  is  attached  ;  the  arched  posterior  border  and  the 
broad  surfaces  are  free  and  are  covered  with  modified  peritoneum,  the  germinal 


58 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


epithelium,  directly  continuous  with  the  serous  covering  of  the  broad  ligament. 
The  position  of  the  ovaries  in  situ  (PI.  8 ;  Figs.  22,  41)  and  during  life,  at 
least  before  the  permanent  displacement  attending  pregnancy  has  taken  place, 


Fundus  of  uterus. 


Utero-marian 
ligament.     \ 


Fig.  48.— Ovary  (natural  size),  with  the  Fallopian  tube  in  relative  position,  of  a  woman  twenty-three  years 
of  age  (Sutton). 

is  probably  such  that  the  long  axes  of  the  organs  are  nearly  vertical  (Wal- 
deyer,  His,  Cunningham)  and  correspond  closely  with  the  sagittal  plane,  so 
that  the  broader   surfaces  may  be   spoken  of  as  mesial  and  lateral  rather 


Rottnd  ligament. 

Fig.  49.— Ovarian  sac  or  recess  on  the  posterior  aspect  of  the  broad  ligament  (modified  from  Richard 
by  Bland  Sutton). 

than  as  anterior  and  posterior.     The  position  of  the  fundus  uteri  is  a  factor 
of  moment  in  determining  the  ovarian  axis,  since,  as  pointed  out  by  His,  the 


ANATOMY    OF    THE    GENERATIVE    ORGAN'S. 


59 


pull  of  the  uterus  when  not  occupying  a  mesial  position  predisposes  to  increased 
obliquity  of  the  ovarian  axis  of  the  opposite  side. 

The  smaller  and  lower  end  of  the  ovary,  or  the  uterine  pole,  points  toward 
the  uterus,  with  which  it  is  united  by  means  of  the  fibro-muscular  bands  consti- 

Fundns  of  uterus. 


Co/:-.  < 'luted  tube. 


Ovary.        Cervix.  Fringes. 

Fig.  51.— Uterus,  tubes,  and  ovaries  of  a  child 
(Sutton). 


Fimbria.  Broad  ligament. 

Fig.  50.— Ovary  and  tube  (natural  size)  of  a  woman  of  sixty-eight  years  (Sutton). 

tuting  the  ovarian  ligament;  the  upper  and  blunter  end,  or  the  tubal  pole, 
after  being  embraced  by  the  arching  oviduct,  receives  the  lower  border  of  the 
fimbriated  extremity  of  the  Fallopian 
tube,  and  is  further  connected  to  the 
wall  of  the  pelvis  by  the  ovario-pelvie 
fold  of  the  peritoneum.  The  ovary 
lies  within  a  peritoneal  recess,  the  fossa 
ovarii  (Claudius),  which  occupies  the 
posterior  part  of  the  side  wall  of  the 
pelvis,  usually  bounded  by  the  internal 
iliac  artery  and  the  ureter  behind  and  the  obturator  vessels  and  nerve  in  front. 
Both  the  anterior  and  posterior  borders  of  the  gland,  as  well  as  its  inner  sur- 
face, are  closely  related  to  and  are  partly  masked  by  the  curves  of  the  oviduct. 

Structure. — The  ovary  is  divided  into  the  cortex  and  the  medulla  (Fig.  52), 
the  boundaries  of  which  are  conventional  and  not  sharply  defined.  The  cortex 
includes  the  peripheral  zone,  containing  the  Graafian  follicles  and  the  ova,  and 
occupies  approximately  the  outer  third  of  the  organ.  The  medulla  embraces 
the  remaining  central  portions  of  the  organ,  in  which  the  blood-vessels,  enter- 
ing through  the  hilum,  are  conspicuous. 

The  bulk  of  the  organ  consists  of  the  ovarian  stroma,  a  peculiar  form  of 
connective  tissue  in  which  lie  imbedded  the  Graafian  follicles,  distinguished  by 
the  great  number  of  its  spindle-cells.  These  cells  are  especially  closely  packed 
in  the  cortex  immediately  beneath  the  surface  covered  by  the  germinal  epi- 


60 


AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 


thelium,  in  which  situation  they  constitute  a  layer  of  greater  density  than  the 
adjacent  stroma,  to  which  the  name  tunica  albuginea  is  applied  ;  this  stratum, 

however,  is  only  a  condensation  of  the  ordi- 
nary stroma  tissue,  and  is  not  an  independent 
envelope. 

The  Graafian  follicles,  the  most  import- 
ant constituents  of  the  cortex,  are  exclusively 
limited  to  this  part  of  the  ovary,  where  they 
occur  in  all  stages  of  development.  The 
least  mature  follicles  consist  of  ova  sur- 
rounded by  a  single  layer  of  flattened  cells, 
the  progenitors  of  the  membrana  granulosa. 
Among  the  immature  follicles  are  others  in 


. 


Fig.  52.— Section  of  human  OTary,  including 
cortex :  a,  germinal  epithelium  of  free  surface ;  b, 
tunica  albuginea;  c,  peripheral  stroma  contain- 
ing immature  Graafian  follicles  (d);  e,  well-ad- 
vanced follicle  from  whose  wall  membrana  granu- 
losa has  partially  separated ;  /,  cavity  of  liquor  fol- 
liculi ;  g,  ovum  surrounded  by  cell-mass  consti- 
tuting discus  proligerus  (Piersol). 


Fig.  53.— Ovary  with  mature  Graafian  follicle  about 
ready  to  burst  (Eibemont-Dessaignes). 


various  stages  of  more  advanced  development,  where  the  ova  are  encircled  by 
two  or  more  rows  of  polygonal  cells  which  by  their  division  give  rise  to  the 
numerous  elements  lining  the  follicle. 

Both  the  ova  and  the  surrounding  cells  are  derivatives  of  the  germinal  epi- 
thelium covering  the  free  surface  of  the  ovary,  from  which  they  dip  into  the 
stroma  as  cylindrical  cell-cords.'  With  the  increase  in  size  which  accompanies 
their  development  the  Graafian  follicles  pass  toward  the  inner  limits  of  the 
cortex  bordering  on  the  medulla,  where  they  undergo  further  enlargement ;  after 
a  time  their  diameter  includes  almost  the  entire  cortex,  and  extends  from  the 
medulla  to  the  surface  of  the  ovary,  the  position  of  the  follicle  becoming  evi- 
dent on  the  free  surface  as  a  distinct  projection  (Fig.  53),  marking  the  point 
at  which  the  final  rupture  of  the  sac  and  the  escape  of  the  ovum  take  place. 

The  mature  Graafian  follicles  appear  as  clear,  slightly  elongated  vesicles  8  to 
12  millimeters  in  diameter;  they  are  defined  from  the  surrounding  tissue  by  a 
condensed  layer  of  the  ovarian  stroma,  the  theca  folliculi.  Within  the  theca  fol- 
lows the  vnembrana  granulosa,  consisting  of  many  layers  of  small  polyhedral 
epithelial  cells.  At  one  point  the  membrana  granulosa  presents  a  thickening 
which  encloses  the  ovum  and  constitutes  the  discus  proligerus.  The  cells  of 
the  discus  next  the  ovum  lie  vertical  to  its  surface,  forming  a  radial  zone,  the 
corona  radiata.  Within  this  layer  lies  the  sexual  cell,  the  ovum,  which  will 
be  considered  more  fully  in  the  section  relating  to  its  development. 

The  formation  of  new  follicles  continues  only  for  a  short  time  after  birth ; 


ANATOMY   OF   THE   GENERATIVE    ORGANS.  61 

ovisacs  are  then  most  numerous,  the  entire  number  contained  within  the  two 
ovaries  of  the  child  being  estimated  at  over  seventy  thousand.  In  view  of 
the  unquestionably  large  number  of  follicles  in  very  young  ovaries,  and  the 
relatively  small  proportion  of  ova  which  reach  maturity,  the  degeneration  of 
many  follicles  after  attaining  a  certain  development  seems  certain.  The  atrophic 
remains  of  such  degenerating  Graafian  follicles  continually  encountered  point 
conclusively  to  the  fate  of  a  large  contingent. 

The  medulla  contrasts  with  the  cortex  by  its  looser  structure  and  the 
number  and  size  of  its  vascular,  and  particularly  its  venous,  canals.  A  con- 
siderable amount  of  involuntary  muscle  is  intermingled  throughout  the  fibrous 
tissue  separating  the  blood-vessels.  Irregular  groups  of  polyhedral  cells  are 
encountered  between  the  fibrous  bundles  of  the  medulla ;  these  elements,  the 
ijiterstitial  cells,  represent  the  remains  of  atrophic  parts  of  the  fetal  Wolffian 
bodies. 

On  the  escape  of  the  ovum,  surrounded  by  the  cells  of  the  discus  pro- 
ligerus,  the  ruptured  and  partly  collapsed  follicle  becomes  filled  with  blood 
poured  out  from  the  torn  vessels  of  the  walls  of  the  follicle.  Subsequent 
changes  lead  to  the  conversion  of  the  follicle  into  a  corpus  luteum.  This 
characteristic  structure  is  formed  by  the  ingrowth  and  rapid  proliferation  of 
the  vascular  tissue  of  the  follicular  wall,  spindle-shaped  connective-tissue  cells 
and  large  cells  containing  yellow  pigment,  lutein,  being  the  most  active  ele- 
ments in  the  process.  The  history  of  the  corpus  luteum  is  materially  affected 
by  the  occurrence  of  pregnancy,  since,  instead  of  being  almost  entirely 
absorbed  within  a  few  weeks,  as  is  the  rule  with  the  ordinary  bodies,  when 
fertilization  takes  place  they  persist  until  after  the  end  of  gestation.  It  is 
usual,  therefore,  to  distinguish  the  corpus  luteum  of  pregnancy,  or  the  corpus 
verum,  from  the  coiyas  luteum  of  menstruation.  The  mode  of  growth  is  iden- 
tical in  both,  the  stimulus  of  impregnation  leading  usually  to  excessive  devel- 
opment. The  primary  blood-clot  occupying  the  ruptured  follicle  becomes 
invaded  by  the  enlarged  and  thickened  wall,  which  soon  becomes  corrugated, 
the  plications  encroaching  upon  the  clot  and  increasing  to  such  an  extent  that 
the  folds  crowd  against  one  another  and  eventually  form  an  irregular  broad 
envelope  surrounding  the  remains  of  the  central  clot.  When  pregnancy 
occurs  the  processes  are  continued  beyond  their  usual  length,  resulting  by  the 
end  of  the  first  month  in  the  production  of  a  mass  from  12  to  20  millimeters 
in  diameter,  characterized  by  a  brilliant  yellow  peripheral  zone  surrounding  a 
lighter  centre.  This  condition  is  succeeded  by  the  gradual  reduction  and  cica- 
trization of  the  central  area  and  the  lighter  tint  of  the  now  greatly  corrugated 
broad  outer  belt.  By  the  end  of  gestation  the  white  nucleus  constitutes  about 
one-third  of  the  entire  corpus  luteum,  which  has  already  become  somewhat 
smaller  (10  to  13  millimeters)  than  at  the  sixth  month.  After  delivery 
absorption  progresses  rapidly,  but  for  some  months  later  the  position  of  the 
corpus  is  distinguishable.  The  characteristic  yellow  color  of  these  bodies  is 
due  to  the  presence  of  a  peculiar  pigment,  lutein,  and  not  merely  to  disinte- 
grated blood. 


62 


AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 


The  peculiarities  distinguishing  the  corpus  Iuteum  of  pregnancy  from  that 
of  menstruation  have  long  been  regarded  as  of  especial  significance  as  supply- 
ing positive  evidence  that  pregnancy  has  taken  place.  While  the  presence  of 
the  typical  yellow  body  must  be  regarded  as  strongly  indicative  of  such  condi- 
tion, the  occasional  encounter  in  the  ovaries  of  undoubted  virgins  of  cor- 
pora lutea  possessing  the  characteristics  of  those  of  pregnancy,  as  recorded  by 


Fig.  54.— Ovaries  of  tv 


Fringes. 

hoving  large  corpora  lutea,  resembling  those  of  pregnancy  (Hirst). 


Hirst  (Fig.  54),  should  lead  to  some  reservation  and  to  a  demand  for  cor- 
roborative evidence  in  the  acceptance  of  these  bodies  as  infallible  signs  of 
the  existence  of  pregnancy. 

The  Parovarium.  —  The  parovarium,  the  epoophoron,  or  the  organ  of 
RosenmuUer,  consists  of  a  group  of  inconspicuous  tubular  structures  within  the 
broad  ligament,  between  the  oviduct  and  the  ovary,  not  far  from  the  attached 
border  of  the  latter  organ  (Fig.  46).  The  parovarium  consists  of  a  series  of 
from  twelve  to  eighteen  short  tubules  which  lie  irregularly  parallel,  their 
ovarian  ends  slightly  converging,  and  which  are  connected  at  their  opposite 
extremities  with  the  longitudinal  head-tube  of  larger  diameter  extending  for 
some  distance  within  the  broad  ligament  toward  the  uterus.  The  tubules  are 
lined  with  low  columnar  epithelial  cells,  the  representatives  of  the  elements 
clothing  the  embryonic  canals. 

The  parovarium  represents  the  partially  obliterated  remains  of  portions  of 
the  Wolffian  body  of  the  fetus ;  the  short  canals  correspond  with  the  tubules 
of  the  body,  while  the  head-tube  is  identical  with  the  upper  part  of  the  Wolff- 
ian duct.  When  this  latter  canal  persists  throughout  the  greater  part  of 
its  original  extent,  it  constitutes  Gartner's  duct,  the  homologue  of  the  vas 
deferens  ;  the  entire  parovarium  corresponds  morphologically  with  the  tubules 
constituting  the  globus  major  of  the  epididymis. 

Additional  fetal  remains  in  the  form  of  rudimentary  tubules  are  sometimes 
encountered  within  the  broad  ligament  in  the  vicinity  of  the  ovary,  although 
situated  rather  nearer  the  uterus  than  the  parovarium.  These  structures  con- 
stitute the  paroophoron,  and  represent  the  atrophic  transverse  tubules  of  the 
lower  part  of  the  Wolffian  body,  being  homologous  with  the  paradidymis  of 


ANATOMY   OF    THE    GENERATIVE    ORGANS. 


63 


Fig.  55— Stalked  hydatid  at- 
tached to  fimbriated  extremity  of 
Fallopian  tube  (New  York  Hospital 
Cabinet). 


the  male.  The  closed  tubules  of  the  paroophoron  are  lined  with  low  columnar 
epithelium  and  are  often  occluded  by  partially  shed  cells.  The  tubules  of  these 
atrophic  organs  possess  a  practical  interest  from 
their  liability  to  become  diseased  and  converted 
into  cysts  which   may  assume  large  diameters. 

The  stalked  hydatid  of  Morgagui  frequently 
forms  a  conspicuous  appendage  to  the  broad  liga- 
ment near  the  fimbriated  extremity  of  the  ovi- 
duct (Fig.  55).  This  pedunculated  vesicle,  which 
varies  greatly  in  size,  represents  the  remains  of 
the  pronephros,  being  common  to  both  sexes.  Low 
columnar  or  cuboidal  epithelium  forms  the  lining 
of  its  dilated  sac  and  stalk  so  far  as  pervious. 

The  Vessels  and  Nerves  of  the  Internal 
Generative  Organs. — The  vascular  and  nervous  supplies  of  the  uterus  and  its 
appendages  and  of  the  ovaries  are  so  intimately  related  that  they  may  conve- 
niently be  considered  together.  These  organs  receive  their  blood  from  three 
sources — the  uterine,  the  ovarian,  and  the  funicular  arteries  (PI.  7). 

The  uterine  artery  is  given  off  from  the  internal  iliac  close  to  the  pelvic 
wall,  along  which  it  runs  as  far  as  the  broad  ligament,  within  whose  folds  it 
then  passes,  in  front  of  the  ureter,  toward  the  cervix  uteri.  After  giving  off 
twigs  which  surround  this  part  of  the  uterus  the  artery  ascends  along  the  body 
of  the  uterus,  sending  off  branches  which  anastomose  with  those  from  the  oppo- 
site side  to  encircle  the  organ.  The  upper  terminations  of  the  uterine  freely 
communicate  with  the  branches  of  the  ovarian  and  the  funicular  arteries. 

The  ovarian  artery,  the  homologue  of  the  spermatic,  is  a  branch  from  the 
abdominal  aorta,  and  gains  entrance  through  the  infundibulo-pelvic  band  into 
the  broad  ligament,  within  which  it  divides  into  its  two  principal  branches — 
the  tubal  and  the  ovarian.  The  tubal  branch  extends  along  the  border  of  the 
oviduct,  dispensing  numerous  twigs  for  the  nutrition  of  the  tube  and  the  tissue 
of  the  broad  ligament.  The  ovarian  proper  is  of  larger  size,  and  passes  close  to 
the  free  border  of  the  ovary,  which  it  particularly  supplies,  finally  anastomosing 
with  the  uterine  and  funicular  arteries  near  the  upper  angle  of  the  uterus. 

The  funicular  artery  is  given  off  from  the  vesical,  after  which  it  joins  the 
round  ligament  at  the  internal  abdominal  ring  and  divides  into  ascending  and 
descending  branches,  the  latter  passing  into  the  labium  along  with  the  liga- 
ment, there  to  anastomose  with  the  external  pudic ;  the  former  ascends  back- 
ward within  the  ligament  as  far  as  the  angle  of  the  uterus,  where  it  joins  the 
ovarian  and  the  uterine  arteries. 

The  veins  of  the  uterus  and  of  the  ovaries  are  large  and  numerous  and 
tend  to  form  plexiform  networks.  Those  of  the  uterus,  always  large,  but  of 
enormous  size  during  pregnancy,  form  a  plexus  within  the  broad  ligament, 
which  plexus  subsequently  gives  place  to  a  trunk  which  accompanies  the 
artery  and  terminates  in  the  internal  iliac  vein.  The  ovarian  veins  are 
particularly  well  developed  in  the  vicinity  of  the  hilum ;  within  the  broad 


64 


AMERICAN    TEXT- BOOK    OF    OBSTETRICS. 


ligament  they  form  an  intricate  meshwork,  the  pampiniform  plexus,  which 
surrounds  the  artery  and  on  the  right  side  terminates  in  the  inferior  cava,  on 
the  left  in  the  renal  vein.  The  subperitoneal  tissue  contains  great  numbers 
of  venous  channels,  the  presence  of  which  is  a  matter  of  practical  import. 
The  lymphatics  (PI.  9,  Figs.  2,  3)  connected  with  the  internal  organs  of  gen- 
eration begin  as  interstitial  lymph-clefts  and  radicles  which  these  viscera,  in  com- 


FlG.  56.— Nerves  of  the  pelvic  organs  of  the  female  (Frankenhausen) :  1,  nerves  to  fundus  of  uterus ; 
2,  right  Fallopian  tube  ;  3,  right  round  ligament;  4,  nerves  to  Fallopian  tube;  5,  communication  between 
ovarian  and  uterine  nerves  ;  6,  ovarian  plexus  of  veins  ;  7,  ovarian  vein ;  8,  nerve  passing  to  join  ovarian 
plexus ;  9,  fimbriated  extremity  of  Fallopian  tube  :  10,  reflected  peritoneum ;  11,  uterine  nerves ;  12,  supe- 
rior hypogastric  plexus  ;  13,  branches  from  hypogastric  plexus  to  uterus  ;  14,  inferior  hypogastric  plexus ; 
15,  vesical  nerves  ;  16,  communicating  branches  to  vesical  plexus ;  17,  cervical  ganglion ;  IS,  branches  of 
hypogastric  plexus  to  cervical  ganglion ;  19,  first  sacral  nerve ;  20,  branches  passing  to  bladder ;  21,  branches 
passing  between  bladder  and  rectum ;  22,  communicating  branches  from  second  sacral  to  cervical  gan- 
glion :  23,  branch  from  third  sacral  nerve  to  cervical  ganglion ;  24,  second  sacral  nerve ;  2.5,  branches  from 
third  sacral  nerve  to  vagina  and  bladder ;  26,  branches  passing  from  fourth  sacral  to  cervical  ganglion. 

mon  with  others,  possess  in  large  numbers.  The  vessels  thus  originating  are 
arranged  as  three  principal  groups  :  1.  The  set  composed  of  those  coming  from 
the  body  of  the  uterus,  the  ovary,  and  the  oviduct,  which  end  in  the  prevertebral 
lymph-glands  in  front  of  the  aorta  and  the  inferior  cava ;  2.  Those  from  the 


EXPLANATION  OP  PLATE  9. 

Fig.  1. — Lymphatics  of  the  uterus,  which  has  been  turned  forward  (Sappey) :  a,  aorta;  B,  common 
iliacs ;  c,  bifurcation  into  internal  and  external  iliacs ;  D,  vena  cava  Inferior ;  E,  common  iliac  veins ; 
F,  uterus  toppled  forward ;  G,  rectum ;  H,  ligament  uniting  sacrum  with  fifth  lumbar  vertebra ;  1,  lymph- 
atic vessels  passing  under  ovaries  to  follow  the  course  of  ovarian  vessels ;  2,  lymphatics  from  body  of 
uterus,  which  end  in  lymph-glands  accompanying  the  iliac  vessels ;  3,  lymph-glands  receiving  the 
lymph- vessels  of  mucous  membrane  of  cavity  of  body ;  4,4,  lymphatics  from  lower  portion  of  surface  of 
uterus,  going  to  the  glauds  behind  internal  iliac  vessels,  which  glands  (5)  vary  in  number  and  volume. 

Fig.  2.— Lymphatics  of  the  pelvic  viscera  and  the  abdomen  (Sappey) :  b,  common  iliacs ;  c,  external 
and  internal  iliacs ;  D,  vena  cava  inferior ;  g,  common  iliac  veins ;  H,  ureters ;  I,  rectum ;  K,  uterus  ;  L, 
cervix ;  M,  M,  section  of  vagina ;  x,  N,  Fallopian  tubes ;  o,  o,  ovaries  ;  Q,  Q,  round  ligament ;  2,  superficial 
renal  lymphatics ;  3,  converging  trunks  of  same,  emptying  into  lymph-glands  (4) ;  7,  7,  lymphatic  plexus 
of  the  ovaries;  8,  9,  trunks  receiving  ovarian  plexus  following  course  of  utero-ovarian  veins;  10,  11, 
glands  receiving  the  lymphatics  from  ovaries  ;  12,  lymphatics  from  fundus,  joining  ovarian  plexus,  with 
same  terminations;  14,  glands  receiving  (13)  trunks  from  surfaces  and  borders  of  body  of  uterus;  15, 
lymphatics  originating  in  lower  part  of  cervix,  mucous  membrane  of  uterine  cavity  and  vaginal  for- 
nices;  16,  lymph-glands  occurring  along  the  course  of  these  vessels  ;  17,  efferent  vessels  of  these  glands 
taking  their  course  to  the  glands  beneath  external  iliac  vessels ;  18,  lymphatics  which  proceed  from 
the  posterior  surface  of  the  cervix,  terminating  in  the  glands  accompanying  the  internal  iliac ;  19,  excep- 
tional lymph-trunk  from  cervix  passing  to  gland  in  front  of  fifth  lumbar  vertebra;  20,  another  excep- 
tional lymph-gland  and  vessel  situated  along  the  course  of  the  common  iliac. 

Fig.  3. — Lymphatics  of  the  breast  (Sappey) :  A,  cellulo-adipose  cushion  supporting  mammary  gland ; 
B,  contour  of  mammary  gland ;  c,  superficial  blood-vessels ;  1,  network  of  superficial  lymphatics ;  2,  net- 
work of  lymphatics  originating  in  and  draining  the  lobules  of  the  gland ;  o,  large  lymphatic  trunks  orig- 
inating in  the  peripheral  network ;  4,  plexus  of  lymphatics  having  their  origin  in  the  deeper  parts  of  the 
gland;  5,  large  vessels  originating  in  the  inner  part  of  this  plexus;  6,  7,  8,  large  lymphatic  trunks. 


GENERATIVE  OEGANS. 


1.  Lymphatics  of  the  uterus,  which  has  been  turned  forward  (Sappey).    2.  Lymphatics  of  the  pelvic  viscera 
and  abdomen  (Sappey).    3.  Lymphatics  of  the  breast  (Sappey). 


ANATOMY   OF    THE    GENERATIVE    ORGANS.  65 

cervix  and  adjacent  part  of  the  vagina,  which  extend  along  the  base  of  the 
broad  ligament  and  terminate  within  the  internal  iliac  glands  of  the  pelvis 
near  the  iliac  artery  at  its  point  of  division  ;  3.  Those  which  accompany  the 
round  ligament  and  pass  to  the  inguinal  glands.  These  latter,  as  in  the  male, 
include  two  groups,  those  lying  along  the  course  of  Poupart's  ligament,  which 
constitute  the  oblique  set  and  receive  the  lymphatics  from  the  genitalia,  and 
those  arranged  about  the  saphenous  opening  as  the  vertical  set,  into  which 
empty  the  superficial  lymphatics  of  the  lower  limb.  The  great  abundance  of 
the  lymphatics  of  the  uterus,  the  cervix,  and  the  vagina  is  a  matter  of  much  prac- 
tical importance,  since  these  channels  furnish  the  paths  by  which  septic  mat- 
ters may  invade  and  affect  parts  widely  removed  from  the  focus  of  infection. 

The  nerves  (Fig.  56)  of  the  uterus,  the  ovary,  and  the  oviduct  are  derived 
partly  from  the  sacral  nerves,  particularly  the  third  and  the  fourth,  and  partly 
from  the  sympathetic  system  as  represented  by  the  hypogastric  and  ovarian 
plexuses.  The  nerves  include,  therefore,  both  medullated  and  pale  fibres,  the 
latter  being  especially  destined  for  the  blood-vessels  and  the  masses  of  invol- 
untary muscular  tissue. 

The  Mammae. — The  mammary  glands,  being  really  but  highly  specialized 
and  greatly  developed  sebaceous  follicles,  belong  to  the  integument,  and, 
strictly  regarded,  have  no  place  among  the  sexual  organs.  The  closely  asso- 
ciated functional  relation  of  these  organs  in  furnishing  the  nutriment  for  the 
newly-born  animal,  however,  as  well  as  convenience,  has  made  it  customary  to 
describe  them  in  connection  with  the  organs  of  generation.  The  present  pur- 
pose will  require  the  consideration  of  the  glands  as  developed  in  the  female 
alone,  the  rudimentary  organs  of  the  male  being  disregarded. 

The  mammary  glands  of  the  human  female  (Fig.  57),  as  seen  in  well-devel- 
oped women  prior  to  pregnancy,  protected  by  the  integument  and  the  fascia?  and 
the  associated  masses  of  adipose  tissue,  collectively  form  a  pair  of  hemispherical 
prominences,  the  breasts,  surmounted  by  the  conical  mammillae  or  nipples. 

The  breasts  as  a  whole  are  not  cpiite  circular  in  outline,  since  their  attached 
bases  present  slight  extensions  inward  over  the  sternum  as  well  as  outward, 
above  and  below,  toward  the  axilla.  Neither  is  the  gland  always  limited  by 
the  deep  fascia,  since  small  aggregations  of  the  glandular  tissue  may  pierce  the 
fascial  septum  and  lie  upon  or  become  imbedded  within  the  pectoral  muscle — 
a  matter  of  much  practical  moment  in  amputations  of  the  mamma  for  malig- 
nant disease. 

The  size  of  the  breasts  depends  so  evidently  upon  the  functional  condition 
of  the  glandular  tissue  and  the  quantity  and  tonicity  of  the  surrounding  adi- 
pose tissue  and  other  protecting  structures  that  the  dimensions  of  the  organs 
must  include  a  wide  latitude  of  variation.  The  breasts  may  be  said  ordinarily 
to  extend  from  the  third  to  the  seventh  rib  and  from  the  sternal  border  to  the 
anterior  axillary  margin,  with  a  prominence  depending  much  upon  the  amount 
of  fat  or  upon  the  condition  of  the  gland.  The  nipple  is  usually  situated  on 
a  line  corresponding  with  the  level  of  the  fourth  rib,  being  directed  somewhat 
outward  and  upward. 


66 


A  ME  HI  CAN   TEXT-BOOK    OF    OBSTETRICS. 


Varying  with  the  general  complexion,  the  nipple  is  of  a  roseate  or  a  pink- 
ish-brown tint,  and  is  surrounded  at  its  base  by  the  areola,  an  area  of  modified 
integument  about  an  inch  in  diameter,  possessing  the  same  color  as  the  nipple. 
The  changes  in  the  appearance  of  this  zone  induced  by  pregnancy  are  more  or 
less  permanent,  the  deeply  pigmented  areola  of  the  dark   brunette  never  re- 


Greater  pectoral  muscle. 

Integument. , 


Glandular  tissue. 
Mass  of  adipose  tissue. 


Lesser  pectoral  muscle. 

Intercostal  muscles. 


Third  rib. 

Deep  fascia. 

Superficial fai 

Fourth  rib. 


Areola.. 
Interlobular  adipose  tissue.~^~_ 

Nipple. -^^^^^     """_  -  "     ,  -     \ 
Lactiferous  duct.  -^5^7^?^  /9  "7-7\ 

Interlobular  adipose  tissue. \J\rY^O^- — fj    ' 

Glandular  tissue. 


Peripheral  acini. 

Mass  of  adipose  tissue. 


■  -:. 


Horizontal  c 
■      nipple. 


Fibrous  septa. 
Integument. 


External  oblique  muscle. - . 

Fig.  57.— Longitudinal  section  of  mammary  gland  in  situ;  frozen  subject  of  twenty  years  (Testut). 


gaining  its  former  tint;  in  light  blondes  the  darkening  of  the  areola  accom- 
panying pregnancy  is  often  very  slight,  and  may  subsequently  almost  entirely 
disappear. 

The  skin  covering  the  areola  is  characterized  by  its  variable  pigmentation, 
by  its  delicacy,  by  the  absence  of  subcutaneous  adipose  tissue,  and  by  the 
presence  of  large  sebaceous  follicles,  and,  in  addition  to  well-developed 
sweat-glands,  small  groups  of  glandular  acini,  the  accessory  milk-glands, 
of  which  from  five  to  twelve  are  usually  present.  The  sebaceous  follicles 
during  pregnancy  become  greatly  increased  in  size  and  form  prominent  ele- 
vations, the  glands  of  Montgomery.     In  addition  to  independent  ducts  open- 


ANATOMY    OF    THE    GENERATIVE    ORGANS. 


67 


ing  on  the  surface  of  the  areola,  the  accessory  glands  sometimes  are  connected 
with  the  milk-tnbes  traversing  the  nipple. 

Both  the  nipple  and  the  areola  contain  numerous  bundles  of  unstriped 
muscular  tissue,  arranged  as  circular 
and  radiating  fibres,  which  respond  to 
mechanical  stimulation.  The  contrac- 
tion of  the  circularly  disposed  fibres 
causes  the  nipple  to  become  more 
prominent  or  "  erected ;"  the  radial 
fibres,  on  the  contrary,  tend  to  depress 
or  retract  the  nipple. 

The  secreting  tissue  of  the  mamma 
consists  of  an  aggregation  of  pyramidal 
masses  (from  fifteen  to  twenty  in  num- 
ber) of  acini  and  ducts  which  corre- 
spond with  the  lobes  composing  the  organ 
(Fig.  58).  Each  lobe  represents  a  single 
highly  developed  and  specialized  seba- 
ceous gland,  whose  excretory  tube  is  the 
lactiferous  or  galactophorous  duct,  and 
whose  secretory  portion  is  the  associated 
group  of  acini. 

The  individual  component  glands, 
the  lobes,  are  invested  by  the  surround- 
ing connective  tissue  which  constitutes  the  general  supporting  framework  of 


Fig.  5S—  Arrangement  of  glandular  tissue 
of  breast,  the  fat  having  been  removed  to  show 
the  ducts  and  acini  (Astley  Cooper). 


SL 


Fig.  59. — Section  of  mamma 


(Siin'ty):  a,  a,  lobules  of  secreting  tissue,  con- 


sisting of  acini  (6,  6)  lined  with  active  epithelium ;  c,  c,  sections  of  excretory  ducts ;  d,  rf,  interlobular 
connective  tissue. 


the  organ  and  the  septa.     The  latter  penetrate  within  the  aggregations  of 
acini  and  subdivide  the  lobes  into  lobules. 


AMERICAN    TEXT-BOOK   OF    OBSTETRICS. 


Before  the  occurrence  of  pregnancy  and  of  the  functional  activity  asso- 
ciated with  lactation  the  secreting  tissue  forms  but  an  insignificant  portion  of 
the  entire  volume  of  the  mamma  (Fig.  59),  but  during  lactation  the  acini 
become  enormously  developed,  the  lobules  of  true  glandular  tissue  being 
readily  discovered  as  nodular  masses  within  the  more  yielding  areolar  adipose 
envelope.  Under  the  stimulus  of  the  unusual  demands  made  upon  the  organ 
under  such  conditions,  it  is  probable  that  new 
glandular  tissue  is  formed  as  extensions  of  the 
existing  acini. 

The  acini  of  the  fully  developed  but  non- 
functionating  organ  are  lined  by  a  single  layer 
of  short  columnar  or  polyhedral  epithelial 
cells,  the  protoplasm  of  which  appears  gran- 
ular. The  cells  rest  upon  a  delicate  ruem- 
brana  propria  which  envelopes  the  acinus  and 
which  is  continued  on  to  the  minute  excretory 
ducts  with  which  the  acini  are  connected. 

These  passages,  lined  with  a  modification 
of  the  glandular  epithelium,  join  with  others 
to  form  larger  tubes,  which  in  turn  take  part 
in  forming  the  interlobular  canals.  These 
canals  are  superseded  by  the  wider  excretory 
tubes  draining  the  entire  lobe,  which,  directly 
or  after  joining  other  tubes,  become  the  con- 
verging lactiferous  or  galactophorons  ducts. 

The  lactiferous  ducts  (Fig.  60)  on  reaching 
the  areola  undergo  dilatation  and  form  the 
Wivpulhe  or  milk-sinuses.  These  ampulla?  lie 
beneath  the  areola,  and  during  lactation  attain 
each  a  diameter  of  from  4  to  6  millimeters, 
constituting  important  reservoirs  for  the  milk 
secreted  during  the  periods  intervening  be- 
tween the  evacuations  of  the  gland.  At  the 
base  of  the  nipple  these  ducts  undergo  a  re- 
duction in  size  and  become  closely  collected, 
the  larger  tubes  occupying  the  centre  of  the 
group;  surrounded  by  areolar  and  muscular  tissues,  they  ascend  to  the  summit 
of  the  mammilla  as  independent  tubes,  where  they  terminate  by  distinct  orifices 
which  open  into  minute  depressions  occupying  the  apex  of  the  nipple. 

The  epithelium  lining  the  ampulla?  and  the  lactiferous  ducts  is  of  the  low 
columnar  or  cuboidal  variety  ;  within  a  short  distance  of  the  termination  of 
the  ducts  upon  the  nipple,  the  lining  of  the  tubes  changes  its  character  to  cor- 
respond with  that  of  the  adjoining  epidermis,  becoming  stratified  squamous. 

The  changes  taking  place  within  the  lining  cells  of  the  acini  on  the  estab- 
lishment of  lactation  are  very  marked.     In  the  earliest  stage  of  activity,  when 


Fig.  60.— Dissection  of  breast,  show 
ing  suspensory  ligaments  and  milk 
ducts  (Astley  Cooper). 


ANATOMY   OF   THE    GENERATIVE    ORGANS.  69 

the  flow  of  milk  first  begins,  many  acini  still  retain  their  primitive  condition 
of  solidity  :  in  such  cases  the  elements  occupying  the  central  parts  of  the 
tubules  undergo  fatty  degeneration,  some  becoming  disintegrated,  while  others 
are  cast  off  as  masses  which  constitute  the  colostrum-corpuscles  found  in  the 
milk  during  the  first  few  days. 

The  uniformly  granular  protoplasm  of  the  cells  at  rest  becomes  invaded  by 
oil-drops  when  functional  activity  begins,  and,  as  secretion  progresses,  it  becomes 
broken  up  and  displaced  by  the  accumulation  of  oil-globules  within  the  cell. 
The  minute  oil-drops  exist  at  first  as  separate  particles,  which  gradually  increase 
in  size  until  they  become  confluent  and  form  a  single  large  globule  occupying 
the  greater  part  of  the  entire  cell.  The  nucleus  in  consequence  is  displaced 
toward  the  periphery,  next  the  basement  membrane,  where  it  lies  imbedded 
within  the  thin  belt  of  protoplasm  occupying  the  outer  zone  of  the  cell. 

The  cells  within  a  single  acinus  generally  contain  very  unequal  amounts  of 
oil ;  some  of  the  elements  are  so  loaded  that  the  entire  cell  is  occupied  by  the 
oil-drop,  while,  on  the  other  hand,  the  neighboring  cells  may  contain  so  little 
oil  that  the  presence  of  the  fatty  particles  is  masked  by  the  protoplasm. 
Between  these  extremes  all  gradations  may  be  found. 

Upon  attaining  a  certain  tension  the  contained  oil-globules,  escaping  in  the 
direction  of  least  resistance,  are  discharged  into  the  cavity  of  the  acinus,  where 
they,  together  with  the  granular  debris  of  old  epithelial  cells,  are  collected 
within  an  albuminous  fluid  and  constitute  the  lactiferous  secretion,  or  milk. 
During  secretion  the  acini  possess  a  comparatively  wide  lumen,  the  epithelial 
layer  forming  but  a  thin  lining  to  the  irregular  spherical  or  tubular  spaces. 

At  the  cessation  of  lactation  the  acini  become  once  more  reduced  to  narrow 
tubules,  many  being  atrophic,  surrounded  by  the  thin  preponderating  areolo- 
adipose  tissue.  With  each  succeeding  pi-egnancy  a  new  period  of  cellular 
activity  and  new  growth  takes  place  in  the  preparation  of  the  gland  for  its 
active  role  during  lactation. 

The  close  of  the  period  of  sexual  activity  is  followed  by  gradual  permanent 
atrophy  of  the  secreting  structures,  so  that  secretions  of  the  mammse  of  aged 
women  show  little  more  than  the  atrophic  remains  of  the  sometime  conspic- 
uous gland-acini  imbedded  within  the  connective  tissue  which,  with  a  variable 
amount  of  fat,  now  constitutes  almost  the  entire  bulk  of  the  organ. 

The  blood-vessels  of  the  mamma  are  derived  from  two  sources :  principally 
from  the  internal  mammary  artery,  through  its  perforating  branches  within  the 
second,  third,  and  fourth  intercostal  spaces,  and  from  the  axillary  artery 
through  the  thoracic  branches,  the  long  thoracic  or  external  mammary  artery 
often  sending  off  robust  twigs  for  the  supply  of  the  gland. 

The  veins  returning  the  blood  from  the  deeper  part  of  the  organ  follow  the 
corresponding  arteries  ;  the  superficial  veins  form  a  subcutaneous  plexus  which 
becomes  conspicuous  during  lactation. 

The  lymphatics  are  very  numerous,  as  demonstrated  by  the  brilliant  prepa- 
rations made  by  Sappey  (PI.  9,  Fig.  3),  and  they  constitute  a  superficial  and  a 
deeper  set.     The  former  exist  as  an  intricate  subcutaneous  network  in  which 


70  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

the  larger  vessels  are  situated  at  the  periphery,  and  join  the  lymph-paths  con- 
verging toward  the  axilla.  The  deeper  lymphatic  vessels  accompany  the 
deeper  veins  and  pass  off  in  two  groups :  one  set  enters  the  axilla  and  termi- 
nates in  the  costal  group  of  axillary  lymph-glands  ;  the  other  takes  its  course 
into  the  thorax  and  communicates  with  the  chain  of  lymphatic  nodules  situated 
behind  the  sternum.  The  profuse  supply  of  lymphatics  and  the  intimate  rela- 
tions these  bear  to  the  lymph-glands  situated  deeply  and  at  some  distance 
greatly  facilitate  the  conveyance  of  infectious  materials  to  other  parts,  there 
to  establish,  as  in  the  case  of  carcinoma  mammas,  new  foci  of  disease. 

The  nerves  supplying  the  mammary  gland  are  derived  from  the  cervical 
plexus  through  the  superficial  descending  supraclavicular  branches,  and  from 
the  fourth,  fifth,  and  sixth  intercostals ;  numerous  sympathetic  filaments 
accompany  the  latter  into  the  substance  of  the  gland. 

Variations  in  the  number  and  position  of  the  mammae  have  frequently 
been  observed.  "While  reduction  in  number  or  absence  of  these  organs  is 
extremely  rare,  increase  in  their  number,  as  well  as  abnormal  location,  is  by 
no  means  of  great  infrequency.  The  nipple  alone  may  be  involved,  being 
either  multiple  or  suppressed,  or  entire  additional  glands  may  be  present. 

Supernumerary  mammae  have  been  observed  in  many  locations,  among  which 
the  arm,  the  axilla,  various  parts  of  the  anterior  body-wall,  the  back,  the 
buttock,  and  the  thigh  are  the  most  conspicuous.  The  interesting  observations 
of  O.  Schultze  on  the  presence  of  definite  "milk-ridges"  along  the  antero- 
lateral aspect  of  the  trunk  in  embryos,  extending  from  the  root  of  the  upper 
limb  to  the  inguinal  region,  suggest  the  location  in  which  supernumerary 
mammse  are  most  frequently  encountered,  such  superfluous  organs  resulting 
from  the  persistence  and  development  of  areas  which  ordinarily  disappear. 
The  presence  of  such  markedly  aberrant  mammse  as  those  found  on  the  back, 
the  arm,  or  the  buttock  is  less  easily  explained,  since  they  arise  probably  in 
consequence  of  the  unusual  development  of  structures  representing  the  ordi- 
nary sebaceous  glands  of  the  integument  of  the  part. 


III.  Physiology  of  the  Female  Generative  Organs. 

1.  Ovulation. — The  differentiation  of  certain  of  the  cells  derived  from  the 
ingrowth  of  the  germinal  epithelium  covering  the  young  ovary  into  the  sexual 
elements  proper,  the  ova,  takes  place  very  early,  so  that  at  birth  the  formation 
of  the  ova  is  already  nearly  completed,  the  production  of  new  cells  after 
birth  being  very  limited,  and  probably  entirely  ceasing  after  the  second  year 
(Bischoff,  Waldeyer).  The  ovaries  of  the  child  of  two  years,  therefore,  con- 
tain the  full  quota  of  ova,  although  the  vast  majority  of  these  cells  always 
remain  immature  and  undeveloped.  The  entire  number  of  these  primitive 
sexual  elements  stored  up  within  the  ovaries  of  the  young  child  has  been  esti- 
mated at  about  seventy  thousand.  While  it  is  probable  that  a  variable  number 
of  the  immature  ova  undergo  partial  development  before  puberty,  yet  the 
advent  of  sexual  maturity  at  that  period  marks  the  establishment  of  the  full 


ANATOMY   OF    THE    GENERATIVE    ORGANS.  71 

and  regular  development  of  the  Graafian  follicles  and  their  contained  ova, 
accompanied  by  the  usual  attendant  phenomena  of  menstruation. 

Throughout  the  entire  childbearing  period,  or  from  about  the  fifteenth  to 
about  the  forty-fifth  year,  the  development  of  the  Graafian  follicles,  terminat- 
ing in  the  rupture  of  the  follicles  and  the  discharge  of  the  ova,  is  continually 
occurring.  The  liberation  of  the  ova  usually  takes  place  at  definite  times, 
which  in  general  coincide  with  the  menstrual  epochs,  one  or  more  ova  being 
set  free  at  each  period.  This  agreement,  however,  is  by  no  means  necessary 
or  invariable,  since  ovulation,  as  the  ripening  and  discharge  of  the  sexual  ele- 
ments is  termed,  undoubtedly  proceeds  independently  of  menstruation. 

The  ripe  human  ovum  is  a  typical  spherical  cell,  about  0.2  millimeter  in 
diameter,  consisting  of  granular  protoplasm  or  the  vitellus,  in  which  lies  a 
nucleus  or  germinal  vesicle,  about  0.045  millimeter  in  diameter,  containing  a 
well-marked  nucleolus,  the  germinal  spot.  The  proper  cell-wall  is  the  vitelline 
membrane,  a  structure  of  great  delicacy,  and  often  overlooked,  outside  of  which 
the  ovum  is  invested  by  the  conspicuous  zona  pettucida  (about  0.01  millimeter 
thick),  which  must  be  regarded  as  a  secondary  envelope  contributed  by  the 
cells  of  the  surrounding  discus  proligerus. 

The  fully-developed  Graafian  follicle  is  ovoid,  and  consists  of  an  external 
investment  of  vascular  connective  tissue,  the  tunica  fibrosa,  which  is  lined  by 
a  thick  layer  of  granular  polyhedral  epithelial  cells,  the  membrana  granulosa. 
At  one  point  these  cells  are  continued  as  a  mass  which  immediately  invests  the 
ovum  and  which  is  known  as  the  discus  proligerus.     The  interior  of  the  well- 


US 


Fig.  61.— Section  of  well-developed  Graafian  follicle  from  human  embryo  (Von  Herff ) ;  the  enclosed 
ovum  contains  two  nuclei. 

developed  follicle  (Fig.  61)  contains  a  fluid,  the  liquor  foUiculi,  separating  the 
ovum  and  its  surrounding  discus  from  the  opposite  wall  of  the  sac.  The  most 
prominent  part  of  the  ripe  follicle  is  less  vascular  than  those  parts  subjected  to 
less  pressure,  one  spot,  the  Jiilum  foUiculi,  being  free  from  blood-vessels,  and 
corresponding  with  the  point  at  which  the  distended  matured  sac,  from  2 
to  4  millimeters  in  diameter,  finally  ruptures. 


72  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

2.  Menstruation. — At  regular  intervals  throughout  the  childbearing  period 
the  lining  of  the  uterus  undergoes  changes  primarily  designed  to  prepare  a 
favorable  resting-place  for  the  product  of  conception.  In  the  case  of  the 
non-occurrence  of  pregnancy  these  changes  terminate  in  the  disintegration  of 
the  uterine  mucous  membrane  and  in  the  discharge  of  blood,  mucus,  and  tissue- 
debris  that  constitutes  the  phenomena  of  menstruation.  Should  pregnancy 
occur,  menstruation  is,  as  a  rule,  suspended  during  the  entire  time  that  the  em- 
bryo is  within  the  uterus,  reappearing  usually  from  six  to  eight  weeks  after  the 
birth  of  the  child.  Exceptions  to  the  customary  prompt  cessation  of  men- 
struation are  by  no  means  infrequent,  the  catamenial  phenomena  often  recurring 
with  regularity  during  the  early  months  of  gestation.  The  anatomical  explan- 
ation of  this  variation  is  found  in  the  fact  that  the  uterine  cavity  is  not  obliter- 
ated by  the  apposition  of  the  decidua  reflcxa  against  the  mucous  membrane  of 
the  uterus  or  the  decidua  vera  until  the  end  of  the  fifth  month.  The  very  rare 
occurrence  of  the  menses  throughout  gestation  is  probably  associated  with  an 
abnormal  and  imperfect  fusion  of  the  deciduas.  The  reputed  instances  of 
women  menstruating  only  during  pregnancy  must  be  viewed  with  suspicion, 
since  the  discharge  in  such  cases  probably  always  results  from  pathological 
conditions  of  the  cervical  canal. 

The  complete  menstrual  cycle,  which  typically  occupies  twenty-eight  days, 
may  be  divided  into  four  stages  (Marshall),  following  one  another  in  regular 
sequence  and  lasting  a  definite  proportion  of  the  entire  period  : 

(1)  The  first  or  constructive  stage  is  one  of  preparation  for  the  reception  of 
an  ovum,  and  is  characterized  by  the  formation  of  a  menstrual  decidua  in  the 
preparation  of  which  swelling  of  the  mucous  membrane,  enlargement  of  the 
uterine  glands,  and  increase  of  the  connective  tissue  all  take  place.  This  stage 
probably  lasts  about  one  week,  and  is  followed,  when  pregnancy  has  not 
occurred,  by  degenerative  change^. 

(2)  The  second  or  destructive  stage  is  marked  by  the  destructive  processes 
which  give  rise  to  the  usual  phenomena  of  the  menstrual  period,  including 
the  discharge  of  mucus,  blood,  and  disintegrated  uterine  mucous  membrane. 
Five  days  constitute  the  average  duration  of  the  menstrual  flow,  although  its 
continuance  may  be  extended  or  curtailed,  owing  to  individual  peculiarities. 

(3)  The  third  or  reparative  stage  is  one  of  repair,  during  which  the  deeper 
and  unaffected  parts  of  the  uterine  mucous  membrane  institute  constructive 
processes  which  within  the  short  period  of  from  three  to  four  days  result  in 
the  formation  of  a  new  mucosa. 

(4)  The  fourth  or  quiescent  stage  includes  the  remaining  twelve  or  four- 
teen days  of  the  menstrual  cycle,  and  represents  the  quiescent  period  preceding 
the  initiative  changes  marking  the  beginning  of  the  next  period. 

The  relations  between  ovulation  and  menstruation  are  of  great  interest,  for, 
although  the  discharge  of  the  ripened  ovum  and  of  the  degenerated  uterine 
decidua  takes  place  usually  simultaneously,  it  is  well  established  that  it  is  neither 
invariably  nor  necessarily  so,  since  authenticated  observations  have  shown  that 
menstruation  may  be  unattended  by  the  liberation  of  an  ovum.     While  these 


ANATOMY   OF   THE    GENERATIVE    ORGANS.  73 

two  processes,  as  a  rule,  may  be  regarded  as  associated,  the  determination  of 
the  exact  relation  between  the  discharged  ovum  and  the  uterine  changes  coin- 
cident!)' taking  place  is  not  yet  positively  established.  It  may  be  assumed 
that  the  first  or  constructive  stage  in  the  cycle  of  uterine  changes  is  particularly 
favorable  for  the  reception  of  the  ovum :  this  being  the  case,  it  is  evident  that 
the  preparation  of  the  uterine  mucous  membrane  cannot  be  directed  toward 
the  reception  of  the  ovum,  whose  discharge  takes  place  with  the  coincident 
menstrual  phenomena,  since  it  is  probable  that  at  least  a  week  is  occupied  in 
the  transit  of  the  egg  from  the  ovary  to  the  uterus.  Marshall's  conclusions, 
that  "the  decidua  of  a  particular  menstrual  period  is  related,  not  to  the  ovum 
discharged  at  that  period,  but  to  the  ovum  discharged  at  the  preceding  period,", 
are  fully  warranted  by  the  more  exact  data  furnished  by  careful  observation. 
The  well-known  coincidence  of  ovulation  and  menstruation  finds  its  partial 
explanation,  at  least,  in  the  marked  congestion  of  the  ovaries  and  the  conse- 
quent stimulation  and  vascular  engoi-gement  which  the  uterus  experiences  by 
reason  of  the  close  arterial  anastomoses  between  the  vessels  of  these  organs, 
the  resulting  turgescence  probably  being  an  important  factor  iu  establishing 
the  menstrual  flow. 


II.  PREGNANCY. 

I.  PHYSIOLOGY  OF  PEEGNANCY. 

I.  Development  of  the  Embryo  and  the  Fetus. 

1.  Maturation  and  Fertilization. — Coincident  with  the  growth  of  the  Graaf- 
ian follicle,  which  culminates  in  the  rupture  of  the  sac  and  the  discharge  of  the 
liquor  folliculi  and  the  egg  surrounded  by  the  discus  proligerus,  the  ovum  passes 
through  a  series  of  changes  collectively  termed  maturation,  by  which  the  female 
sexual  cell  is  prepared  for  the  reception  of  the  male  element,  without  the  com- 
pletion of  which  preparation  fertilization  of  the  ovum  is  impossible. 

The  maturation  of  the  ovum  consists  essentially  in  the  very  unequal  and 
repeated  division  of  the  egg,  by  which  two  minute  portions  of  its  substance, 


Fig.  62.— Portions  of  ova  of  Arteritis  glacialis,  showing  changes  affecting  the  germinal  vesicle  at  the 
beginning  of  maturation  (Hertwig):  a,  germinal  vesicle;  b,  germinal  spot,  composed  of  nuclein  and 
paranuclein  (c) ;  d,  nuclear  spindle  in  process  of  formation. 

the  polar  bodies,  are  extruded  ;  the  remainder  of  the  cell  after  the  completion 
of  this  cycle  returns  to  a  quiescent  condition  to  await  the  advent  of  the  male 
sexual  element.     Maturation  takes  place  entirely  independently  of  the  influ- 


O— t 


Fig.  63.— Formation  of  polar  bodies  in  ova  of  Asterias  glacialis  (Hertwig) :  ps,  polar  spinale  ;  pb',  first  polar 
body ;  pb",  second  polar  body ;  n,  nucleus  returning  to  condition  of  rest. 

ence  of  the  male  or  of  the  probability  of  fertilization,  every  healthy  ovum 
undergoing  these  changes  before  it  becomes  sexually  ripe. 

The  process,  in  brief,  consists  of  the  following  phases  :  («)  The  migration 
of  the  germinal  vesicle  or  nucleus  toward  the  periphery  of  the  cell  (Fig.  62) ; 
(6)  the  rupture  and  the  disappearance  of  the  nucleus,  and  the  formation  of  the 


PHYSIOLOGY   OF  PREGNANCY.  75 

nuclear  spindle  and  other  elements  of  the  complicated  mitotic  cycle  of  indirect 
cell-division  ;  (c)  the  extrusion  of  a  minute  portion  of  the  ovum  as  the  first 
polar  body  (Fig.  63)  ;  (d)  short  quiescence  followed  by  a  repetition  of  division, 
resulting  in  giving  off  the  second  polar  body ;  (e)  the  establishment  of  equi- 
librium, the  appearance  of  a  new  and  smaller  nucleus,  the  female  pronucleus 


Fig.  64.— A,  mature  ovum  of  echinus  :  n,  female  pronucleus ;  B,  immature  ovarian  ovum  of  echinus 
(Hertwig). 

(Fig.  64),  and  the  return  to  a  condition  of  rest.'*  Maturation  usually  takes 
place  just  before  the  rupture  of  the  follicle  and  the  escape  of  the  ovum. 

On  the  completion  of  the  phenomena  of  maturation,  the  ovum  is  prepared 
for  the  reception  of  the  male  element,  the  meeting  of  the  sexual  cells  in  mam- 
mals usually  taking  place  within  the  upper  portion  of  the  oviduct. 

In  order  to  appreciate  the  significance  of  maturation,  as  now  accepted  by 
embryologists,  it  is  necessary  to  take  into  account  certain  of  the  structural 
details  of  the  sexual  cells. 

The  nucleus  of  the  ovum  possesses,  in  common  with  other  typical  cells, 
a  reticulum  of  nuclear  fibres  containing  a  substance  known  as  chromatin, 
which  is  the  vehicle  by  which  the  maternal  characteristics  are  transmitted 
to  the  offspring.  During  the  division  of  the  ovum  incident  to  maturation 
the  chromatin  becomes  arranged  as  curved  or  looped  segments,  the  chromo- 
somes, of  which  an  invariable  and  fixed  number  is  always  present  in  the  cells 
of  a  given  species  ;  the  number  of  chromosomes  in  man  is  placed  at  sixteen. 
In  the  course  of  the  mitotic  changes  affecting  the  dividing  ovum  each  chro- 
mosome splits  longitudinally  into  two  chromatin  threads,  the  entire  number 
of  chromatic  segments  being  thereby  doubled.  The  later  phases  of  mitosis 
bring  about  a  redistribution  of  the  chromatic  substance,  so  that  each  new 
nucleus  resulting  from  the  division  receives  exactly  one-half  of  the  chroma- 
tin of  the  maternal  cell,  but  the  same  number  of  segments,  the  constancy  of 
this  definite  number  being  thereby  maintained. 

Brief  reference  to  the  manner  in  which  the  male  sexual  elements  are  pro- 
duced is  necessary  for  the  interpretation  of  the  significance  of  the  division 
of  the  ovum  which  occurs  during  maturation.  The  spermatozoa  are  the 
direct  descendants  of  the  cells  lining  the  seminiferous  tubules.  Certain  of 
these  elements,  the  primary  spermatocytes,  undergo  mitotic  division  whereby 
the  chromatin  is  equally  distributed  to  the  resulting  cells,  the  secondary  sper- 
matocytes; each  of  these  daughter-cells,  in  turn,  gives  rise  to  other  elements, 


76  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

the  spermatids,  which  are  directly  transformed  into  spermatozoa.  These 
latter  elements,  therefore,  are  cells  of  the  third  generation  and  contain  in  the 
so-called  "head"  the  chromatin  of  the  spermatid,  corresponding  in  their 
genealogical  relations  with  the  ovum  after  maturation,  which,  likewise,  io  the 
representative  of  the  third  generation-  resulting  from  the  repeated  division 
of  the  maternal  cell.  In  the  light  of  these  facts,  the  polar  bodies  may  be 
regarded  as  abortive  ova  cast  off  in  order  to  bring  the  female  germ-cell  into 
morphological  correspondence  with  the  male  element. 

An  additional  consideration  of  great  importance  must  be  noted  before  the 
full  significance  of  the  preparatory  changes  anticipating  the  union  of  the  two 
germ-cells  during  fertilization  can  be  appreciated.  Bearing  in  mind  the  fact 
already  stated,  that  the  number  of  chromosomes  is  constant  in  the  cells  of 
any  given  species,  it  is  evident  that  union  of  the  parent  elements  would 
result  in  numerically  doubling  the  chromatin  segments  in  the  new  being 
were  not  some  provision  made  by  which  the  number  of  chromosomes  of  the 
sexual  cells  was  reduced  to  one-half  the  normal  number  in  each.  As  a 
matter  of  observation,  such.pe'1  uetiov  does  take  place  during  the  development 
of  both  sexual  cells,  so  rn«  '  in  man  the  spermatozoon,  on  the  one  hand,  and 
the  ovum  after  maturation,  on  the  other,  each  contains  only  eight  chromo- 
somes, the  normal  number,  sixteen,  being  restored  only  after  the  intermin- 
gling of  the  contributions  from  both  parents  in  the  nucleus  from  which 
segmentation  proceeds. 

The  number  of  the  more  vigorous  seminal  elements  deposited  within  the 
vagina  that  work  their  wa}'  through  the  uterine  cavity  and  into  the  oviducts 
must  be  but  an  insignificant  part  of  the  entire  number  lodged  about  the  exter- 
nal os.     Of  those,  moreover,  fortunate  enough  to  overcome  the  obstacles  pre- 


Fig.  65. — Portions  of  the  ova  of  Astenas  glacialis,  showing  the  approach  and  fusion  of  the  spermatozoon 
-with  the  ovum  (Hertwig) :  a,  fertilizing  male  element;  ft,  elevation  of  protoplasm  of  egg;  V,  b",  stages 
of  fusion  of  the  head  of  the  spermatozoon  with  the  ovum. 

sented  to  their  progress  within  the  uterus  and  tubes,  but  a  single  spermatozoon 
actually  takes  part  in  the  fertilization  of  the  ovum. 

After  reaching  the  surface  of  the  egg  and  penetrating  the  zona  pellucida, 
the  successful  spermatozoon  is  met  by  a  slight  projection  of  the  protoplasm  of 
the  ovum,  with  which  the  head  of  the  male  element  soon  becomes  blended 
(Fig.  65).  The  tail  is  lost,  and  the  head  later  sinks  within  the  substance  of 
the  egg.     Subsequently  the  position  of  the  impregnating  element  is  indicated 


PHYSIOLOGY   OF  PREGNANCY.  77 

by  the  appearance  of  a  small  round  or  ovoid  body,  the  male  pronucleus  (Fig. 
66,  A,  b),  which  contains  the  paternal  chromatin  represented  by  the  eight 
chromosomes  into  which  the  head  of  the  spermatozoon  soon  becomes  resolved  ; 
the  position  of  the  male  pronucleus,  or  sperm-nucleus,  as  this  structure  is  now 
frequently  termed,  is  rendered  conspicuous  by  the  radial  striation  marking 
the  surrounding  protoplasm.  The  male  and  female  pronuclei  now  approach, 
and  sooner  or  later  meet,  their  chromosomes  forming  two  groups  of  chro- 
matic segments  for  the  resulting  secjmentation-nucleus  (Fig.  66,  c),  from  which 
are  formed  the  new  generations  of  elements,  to  the  constitution  of  which  both 
parent-cells  have  thus  contributed. 

It  is  of  interest  to  note  that,  since  the  parts  of  the  sexual  cells  most  con- 
cerned in  the  production  of  the  segmentation-nucleus  are  rich  in  chromatin, 
a  fusion  of  the  nuclei  seems  to  be  the  essential  feature  of  the  process  of  fer- 
tilization. The  contribution  of  an  equal  number  of  chromosomes  by  each 
parent-cell  to  the  segmentation-nucleus  furnishes  the  explanation  as  to  the 
fundamental  manner  of  transmission  to  the  offspring  of  the  individual  pecu- 
liarities of  both  father  and  mother,  since  the  nejpr.  being  depends  for  its  origin 
upon  a  nucleus  to  which  both  parents  have  cbT'sjibuted  and  by  which  the 
characteristics  of  both  are  perpetuated. 

Should  the  matured  female  element  fail  to  meet  the  spermatozoon,  the 
ovum  after  a  few  days  loses  its  vitality  and  perishes.  The  period  during 
which  the  human  egg  retains  the  possibility  of  fertilization  has  been  variously 
estimated,  about  eight  days  being  the  probable  limit  of  the  retention  of  this 
power,  since  the  death  of  the  unfecundated  ovum  usually  occurs  before  the  egg 
reaches  the  uterus. 

2.  Segmentation. — The  meeting  and  fusion  of  the  male  and  female  pro- 
nuclei, already  described,  result  in  the  formation  of  the  new  segmentation- 
nucleus  (Fig.  66,  C),  whose  appearance  institutes  the  process  of  cell-division  by 


J 


Fig.  66.— A,  fertilized  ova  of  echinus  (Hertwig) :  the  male  (a)  and  the  female  pronucleus  (6)  are 
approaching ;  in  B  they  have  almost  fused ;  C,  ovum  of  echiuus  after  completion  of  fertilization  (Hert- 
wig) :  s.n.,  segmentation-nucleus. 

which  the  original  egg-cell  gives   rise  to  an  extended  series  of  generations, 
leading  to  the  production  of  the  blastoderm. 

Since  the  youngest  human  embryo  carefully  examined  and  recorded — that 
of  Peters — was  already  probably  nearly  four  days  old,  the  early  phenomena 
of  impregnation  and  segmentation  have  never  been  observed  in  man.    Direct 


78  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

observations  upon  higher  mammals,  as  the  clog,  the  mouse,  and  the  rabbit,  have 
supplied  our  knowledge  of  the  details  of  these  early  stages  of  development, 
which,  in  the  main,  probably  closely  correspond  with  the  changes  taking  place 
within  the  human  ovum.  Nagel's  examination  of  a  ripe  human  ovum  and  the 
discovery  of  the  presence  of  two  polar  bodies,  as  in  other  mammals,  still 
further  justify  the  assumption  of  this  similiarity. 

The  minute  amount  of  food-yolk  possessed  by  the  mammalian  egg  is  uni- 
formly distributed  throughout  its  protoplasm,  and  is  not  collected  as  a  distinct 
body ;  such  ova  are  therefore  known  as  alecithal.  As  influenced  by  the 
amount  and  arrangement  of  the  yolk,  these  ova  experience  entire  cleavage 
during  their  division,  and  are  said  to  undergo  total  segmentation,  being  there- 
fore holoblastic.  Since  the  resulting  cells  may  be  regarded  as  practically  equal 
in  size,  their  type  of  segmentation  may  further  be  designated  as  equal.  The 
human  ovum,  therefore,  is  technically  described  as  an  alecithal,  holoblastic 
egg  undergoing  equal  segmentation. 

Almost  directly  after  the  formation  of  the  nucleus  of  segmentation  the 
phenomena  of  cell-division  acppear  within  the  parent-cell,  the  cycle  resulting 
in  the  formation  of  the  first  pair  of  daughter-cells  (PI.  10,  Figs.  1-3).  These 
cells  in  turn  become  the  seat  of  similar  activity  by  which  four  cells  are  pro- 
duced, the  process  of  cell-division  continuing  until  the  original  element  is  rep- 
resented by  many  generations  of  direct  offspring.  While,  for  convenience,  the 
segmentation  of  the  mammalian  egg  may  be  regarded  as  equal,  yet,  when 
closely  examined  after  the  third  or  fourth  cleavage,  a  slight  difference  may  be 
noted  in  the  size  of  the  resulting  elements,  or  blastomeres.  This  discrepancy, 
insignificant  in  its  individual  variation,  becomes  gradually  manifested  by  the 
separation  of  the  blastomeres  into  an  inner  and  an  outer  cell-group,  the  cells  of 
the  outer  group  undergoing  more  rapid  increase  than  those  of  the  inner  group, 
■which  latter  cells,  in  consequence  of  this  inequality  in  growth,  gradually  are 
invested  by  an  enveloping  layer  composed  of  the  outer  cells  (PI.  10).  This 
process  of  covering-in  progresses  until  the  outer  cells  constitute  a  complete 
envelope,  the  entire  segmented  ovum  now  corresponding  with  the  mulberry 
mass,  or  morula,  of  the  older  anatomists. 

Examined  in  section,  the  ovum  at  this  stage  consists  of  the  single  layer  of 
outer  cells,  to  the  inner  surface  of  which  at  one  point  adheres  the  less- 
expanded  group  composed  of  the  inner  cells,  the  space  between  the  two,  the 
segmentation-cavity,  being  occupied  by  a  clear  albuminous  fluid.  This  stage 
of  the  hollow  sphere  of  the  mammalian  ovum  is  known  as  the  blastula  or 
blastodermic  vesicle  (PI.  10,  Fig.  4). 

The  further  changes  within  the  blastula  are  marked  by  the  rapid  and 
enormous  increase  in  the  size  of  the  ovum,  in  consequence  of  which  increase 
the  outer  cell-layer  undergoes  great  extension,  with  corresponding  attenuation 
of  its  elements,  which  are  changed  into  thin,  scale-like  plates. 

Coincidently  with  these  changes  affecting  the  layer  of  outer  elements,  the 
group  of  inner  cells  has  undergone  an  important  although  inconspicuous 
modification,  in  consequence  of  which  a  differentiation  of  these  cells  into  a 
rapidly  proliferating  peripheral  layer,  next  the  thinned-out  stratum  of  invest- 


SEGMENTATION   OF  THE   OVUM. 


Segmentation— 1-3.  Diagrams  illustrating  the  segmentation  of  the  mammalian  ovum  (Allen  Thompson,  after 
E.  t.  Beneden).    4.  Diagram  representing  the  relation  of  the  primary  layers  of  the  blastoderm  (Bonnet). 


PHYSIOLOGY    OF  PREGNANCY.  79 

itif  outer  cells,  and  a  more  slowly  dividing  central  mass  has  taken  place 
(PI.  10,  Figs.  1-3).  This  peripheral  layer  is  the  primitive  ectoderm  proper  ; 
the  inner  mass  is  the  primitive  entoderm. 

With  the  growth  of  the  eetodermic  layer  the  primary  outer  cells  become 
more  attenuated,  and  after  a  time  blend  with  the  developing  eetodermic  tissue, 
the  two  together  constituting  the  early 
true  ectoderm.  When  this  structure  is 
examined  its  surface  is  found  covered 
with  flat  elements,  fusiform  in  profile, 
known  as  Rauber's  cells  (PI.  10,  Fig.  4), 

.  ,  #V"  -  :->i         Node  of 

which  later  disappear  and  seemingly  take    ft-  $§5         '■      ~*r^     //<•««•« 

.  .  „  f  ?M —  Neunnteric 

little  or  no  role  in  the  formation  of  the 
permanent  eetodermic  structures.  The 
cells  of  Rauber  are  probably  the  remains 
of  the  attenuated   layer  of  the  primary 

outer  cells.    The  ectoderm  expands  on  all       %  f~i~- / —  Fr"t"l'akC 

.sides   until  the  entoderm   as  well   as  the  f*. 

.entire  yolk-cavity   of  the  ovum  is  com-  .,.■'....  '.  J 

pletely  enclosed.  \        ■  /' 

If  a  mammalian  ovum  at  about  this  ~* ■■=-'- 

i  -.     n  ,,  n  xl  Fig.  67.— Embryonic  area  of  rabbit  embryo 

stage  be  examined  from  the  surface,  the  (E>  T.  Beneaen):  primitive  streak  beginning 

blastodermic  vesicle   on    one  side   presents    in  cell-proliferation,  known  as  the  "  node  of 

an  oval  or  pyriform  field  of  greater  den- 
sity :  this  is  the  embryonal  area,  and  corresponds  to  that  portion  of  the  blastula 
especially  concerned  in  the  development  of  the  embryo.  Very  early  a  linear 
opacity  known  as  the  primitive  streak  (Fig.  67)  makes  its  appearance  at  the 
smaller  or  posterior  pole  of  the  embryonal  area,  and  seemingly  grows  for- 
ward toward  the  centre  of  this  field. 

On  section  the  primitive  streak  is  seen  to  depend  upon  a  line  of  proliferat- 
ing tissue  which  marks  the  position  of  fusion  and  intimate  union  of  all  the 
■embryonal  blastodermic  layers  (Figs.  68,  69).  Very  soon  the  primitive  streak 
becomes  occupied  by  a  median  longitudinal  furrow,  the  primitive  groove.  The 
significance  of  this  pre-embryonic  structure  is  still  a  subject  of  much  discussion. 
Without  entering  into  the  details  of  the  somewhat  theoretical  and  complicated 
considerations  of  the  subject,  it  may  be  mentioned  that  there  are  ample  grounds 
for  accepting  the  views  of  His,  Minot,  and  others  that  the  primitive  streak  of 
the  higher  types  represents  morphologically  the  fusion  of  the  lips  of  the  blas- 
topore— the  opening  formed  among  the  lower  types  by  the  invagination  of  the 
blastodermic  vesicle  at  one  point  in  the  production  of  the  gastrula  stage. 

In  contrast  with  the  usual  appearance  of  mammalian  ova,  the  early  human 
ovum  is  characterized  by  the  precocious  development  of  villous  projections, 
so  that  as  early  as  the  twelfth  day,  as  represented  by  Rei chert's  ovum  (see 
Fig.  83),  its  exterior  presents  well-marked  elevations.  These  villi,  however, 
are  not  uniformly  distributed  over  the  ovum,  but  are  limited  to  the  marginal 
zone  of  the  compressed  spherical  egg,  the  two  flattened  sides  being  smooth 
.and  devoid  of  villi.     The  embryonic  area  corresponds  in  position  with  one  of 


80 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


the  poles  of  the  shorter  axis  of  the  ovum  that  connects  the  smooth  sides, 
although  at  this  stage  little  if  any  trace  of  the  embryo  is  to  be  seen. 

Coincidently  with  the  further  growth  and  differentiation  of  the  two- 
layered  blastula,  a  third  layer,  the  mesoderm,  makes  its  appearance  (Fig.  68). 
The  origin  of  this  lamina  is  still  a  subject  of  much  discussion,  but  it  may  be 
accepted  as  demonstrated  that  the  mammalian  mesoderm  arises  from  "two- 
sources — principally  by  a  splitting  off  or  delamination  from  the  entoderm. 


Fig.  68.— Section  across  the  primitive  streak  of  rabbit  embryo  (Kolliker) :  ec,  ectoderm  ;  ax.  ec,  axial  ecto- 
derm undergoing  proliferation,  as  shown  by  karyokinetic  figures  (k) ;  ent,  entoderm ;  m,  mesoderm. 

supplemented  by  a  proliferation  involving  the  ectoderm  along  the  anterior 
part  of  the  primitive  streak.  This  latter  structure  therefore  marks  the  axis 
along  which  complete  fusion  of  the  three  blastodermic  layers  takes  place 
before  the  formation  of  the  true  embryo  has  started.  The  primitive  streak 
is  a  transient  structure,  and  gives  rise  to  no  part  of  the  embryo ;  later  it 
entirely  disappears. 

The  growth  of  the  mesoderm  is  rapid,  and  soon  produces  a  layer  partic- 
ularly developed  toward  the  caudal  pole  of  the  embryo,  expanding  in  broad 
lateral  fields  on  either  side.  Viewed  as  a  whole,  the  mesodermic  sheet  appears 
pyriform,  with  its  smaller  end  directed  anteriorly  or  opposed  to  the  corre- 
sponding   part   of  the   embryonal    area.     At    first    a   continuous    layer,    the 


Parietal 
Ectoderm.    \„{esoci'e. 


Visceral  layer 
of  mesoderm.  Entoderm. 

Fig.  69.— Transverse  section  of  the  embryonic  area  of  a  fourteen  and  a  half  day  ovum  of  sheep  (Bonnet).. 

mesoderm  later  becomes  displaced  along  the  immediate  axis  of  the  embryo, 
this  division  resulting  in  the  formation  of  two  closely  approximated  but 
separated  halves  :  in  each  of  these  a  paraxial  and  a  lateral  tract  are  further  to 
be  recognized.  The  latter  undergoes  cleavage  by  the  formation  of  the  intra- 
mesodermic  body-cavity  or  the  celom  (Fig.  69) ;  the  resulting  upper  and  lower 
lamella;  constitute  respectively  the  parietal  and  visceral  layers  of  the  meso- 
derm.    The  parietal  or  somatic  layer  joins  the  ectoderm  to  form  the  somato- 


PHYSIOLOGY    OF  PBEGNANCY.  81 

pleure;  the  visceral  or  splanchnic  layer  unites  with  the  entoderm  to  form 
the  splanchnopleure  (Fig.  70).  These  structures  later  produce  the  body-walls 
and  the  walls  of  the  primitive  digestive  tube. 

About  the  end  of  the  second  week  the  human  ovum  enters  upon   the 
earliest  initial  stages  of  the  formation  of  the  embryo  proper.     In  addition  to 


Lateral  plates/or 
body-ivalls. 


Lateral  plates  fc 
gut-tract. 


Parteta!  we.Wi/er 


Vitellin 
Fig.  70.— Transverse  section  of  a  seventeen  and  a  half  day  sheep  embryo  (Bonnet). 

the  primitive  streak,  which,  as  above  stated,  is  a  transient  structure  having 
nothing  directly   to  do  with    the  embryo,   the    fundamental    developmental 
processes  include  the  formation  of  the  neural  folds  and  the  neural  canal, 
the  chorda  dorsalis  or  noto- 
chord,    and    the    somites    or 
provertebraz. 

Neural  Canal. — The  de- 
velopment of  this  structure 
consists  first  in  the  appear- 
ance of  the  neural  or  medul- 
lary folds,  which  together 
constitute  a  A-shaped  dupli- 
cature  embracing  the  anterior 
extremity  of  the  primitive 
streak ;  by  the  thickening 
and  the  approximation  of  the 
summits  of  these  folds  the 
neural  or  medullary  groove  is 
produced  (Fig.  71).  This 
furrow  is  later  converted  into 
the  neural  canal,  the  early 
representative  of  the  nervous 
system,  by  the  further  growth 
and  union  of  the  folds  along  the  dorsal  line  of  contact,  the  closure  being  first 
effected  near — not,  however,  at — the  cephalic  extremity  of  the  embryo,  but 
some  little  distance  farther  caudally,  at  a  position  which  later  corresponds  with 


Fig.  71.— Surface  view  of  area  pellucida  of  an  eighteen  hour 
chick  embryo  (Balfour). 


82 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


the  cervical  region  of  the  spinal  cord.  The  extreme  cephalic  end  of  the  neural 
canal  undergoes  expansion  into  three  primitive  brain-vesicles.  The  neural 
folds  of  the  caudal  portion  for  a  long  time  remain  widely  separated. 

Chorda  Dorsalis. — The  appearance  of  the  chorda  dorsalis,  or  the  notochord, 
establishes  the  earliest  representative  of  the  longitudinal  axis  which  constitutes 
the  fundamental  characteristic  of  all  vertebrates.  The  earliest  development 
of  this  structure  in  man,  recently  observed,  shows  the  close  correspondence 
of  the  process  in  the  human  embryo  with  that  in  other  mammals.  The 
mesial  portion  of  the  entoderm  gives  rise  to  a  cell-group  (Fig.  72)  which 
gradually  becomes  separated  from  the  inner  layer  and  displaced,  so  that  the 


Ccll-massfor 
Wolffian  body. 

Celom. 

31,'M>!h<*lium. 


Notochord. 
Fig.  72.— Transverse  section  of  a  fifteen  and  a  half  clay  sheep  embryo  possessing  seven  somites  (Bonnet). 


resulting  cell-mass  forms  a  ^lender  cylinder  which  stretches  from  the  anterior 
extremity  of  the  embryo  to  its  caudal  pole.  On  section  the  notochord  appears 
as  an  oval  group  of  cells  situated  immediately  beneath  the  neural  groove  or 
canal  and  above  the  entodermic  layer  (Fig.  74).  The  notochord,  for  a  time 
representing  the  longitudinal  axis  of  the  embryo,  is  usually  replaced  by  the 
permanent  vertebral  axis,  at  first  cartilage  and  later  bone.  The  remains 
of  this  embryonal  structure  in  man  are  seen  in  the  central  areas  of  spongy 
material  occupying  the  intervertebral  disks. 

Somites. — The  formation  of  the  somites  or  prevertebral  marks  the  estab- 
lishment of  the  segmentation  which  later  is  permanently  effected  by  the  devel- 
opment of  the  vertebrae  and  the  associated  parts  of  the  trunk.  The  production 
of  the  somites  is  so  closely  related  to  that  of  the  mesoderm  that  the  primary 
arrangement  of  this  important  sheet  must  be  recalled.  After  its  origin  from 
the  double  source  of  entoderm  and  ectoderm,  the  mesoderm  rapidly  expands 
laterally,  the  growth  being  particularly  active  toward  the  caudal  pole  of  the 
embryo,  in  consequence  of  which  the  layer  becomes  pyriform  in  outline  when 
seen  from  its  upper  surface.  At  first  a  continuous  sheet,  the  further  develop- 
ment of  the  neural  groove  from  above  downward  and  of  the  notochord  from 


PHYSIOLOGY   OF  PREGNANCY. 


below  upward  soon  divides  the  mesodermic  tract  along  the  embryonic  axis  into 
two  great  wings  (Fig.  73). 

Each  of  these  wings  undergoes  further  differentiation  into  a  paraxial  band 
next  the  mid-line,  and  a  lateral  plate  which   blends  away  laterally  into  the 


Pleur  _ 
dial  cavity. 

Fig.  73.— Transverse  section  of  a  sixteen  and  a  half  day  sheep  embryo  (Bonnet). 

widely  extending  mesodermic  area  (Fig.  74).  The  lateral  mesodermic  plate 
undergoes  cleavage  into  an  upper  and  a  lower  lamina  which  respectively 
adhere  to  the  ectoderm  and  the  entoderm.  The  upper  and  outer  of  the  result- 
ing two-layered  lamella?  constitutes  the  somatopleure;  the  under  and  inner  one, 


Notocliord '.  Somite.     Gut  entoderm. 

Fig.  74.— Transverse  section  of  a  sixteen  and  a  half  day  sheep  embryo  possessing  six  somites  (Bonnet). 

the  splanchnopleure.  The  space  included  between  the  two  leaves  of  the  cleft 
lateral  mesoderm  is  the  primitive  body-cavity  or  celom,  which  afterward  becomes 
the  pleuro-peritoneal  cavity. 


84  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

The  paraxial  band  of  mesoderm  does  not  undergo  cleavage  as  do  the 
neighboring  lateral  mesodermic  areas,  but  instead  it  suffers  a  transverse  divis- 
ion into  a  series  of  small  quadrilateral  areas,  the  somites  or  provertebros. 
These  areas  first  appear  immediately  behind  the  cephalic  expansion  of  the 
neural  canal  and  progress  toward  the  caudal  pole,  at  particular  stages  of  the 
human  embryo,  as  from  the  twenty-first  to  the  thirty-fifth  day,  forming  a 
series  of  usually  thirty-seven  conspicuous  markings  on  each  side  of  the 
dorsal  mid-line  as  far  as  the  extreme  caudal  extremity  (Fig.  129), 

The  somites,  as  such,  are  transient  and  are  not  directly  represented  by 
adult  structures,  since  the  permanent  vertebras  which  later  appear  do  not 
correspond  with  the  somites.  Each  somite  contains  a  central  core  of  loose 
mesodermic  tissue  which  breaks  through  the  mesial  boundary,  forming  a  fan- 
shaped  mass  known  as  the  sclerotome,  from  which  the  permanent  vertebrae 
are  developed.  The  remaining  poi'tions  of  the  somite  become  differentiated 
into  a  lateral  and  a  mesial  mass,  called  respectively  the  skin-plate  and  the 
muscle-plate;  the  former  contributes  the  cutis  vera,  the  latter  the  primary 
segmented  voluntary  muscular  tissue  of  the  trunk,  from  which  later,  when 
the  extremities  appear,  the  limb-muscles  are  derived. 

•3.  Petal  Membranes. — Coincident]}'  with  the  progress  of  the  fundamental 
processes  just  described,  the  formation  of  envelof>es  for  the  protection  and 
establishment  of  means  for  the  further  nutrition  of  the  embryo  takes  place : 
these  envelopes  are  known  as  the  fetal  membranes  (Pis.  11,  12),  which,  in  con- 
nection with  the  structures  derived  from  the  thickened  uterine  lining,  con- 
stitute the  membranes  thrown  off  at  birth. 

The  amnion  (PI.  11,  Figs.  4,  5),  the  earliest  of  the  envelopes,  appears  soon 
after  the  formation  of  the  neural  folds  and  groove  as  duplicatures  of  the  soma- 
topleure  which  start  in  front,  behind,  and  at  the  sides  of  the  embryo.  The 
anterior  amniotic  fold  in  man  grows  with  unusual  rapidity,  and,  aided  by  the 
lateral  folds,  soon  covers  in  the  embryo  from  before  backward,  the  caudal 
extremity  being  the  last  to  be  enveloped.  The  line  of  union  of  the  several 
duplicatures  has  received  the  name  amniotic  suture.  Examined  in  section,  the 
amnion  is  seen  to  comprise  not  only  the  ectodermic  tissue,  but  also  the  exten- 
sion of  the  parietal  or  somatopleuric  layer  of  the  mesoderm.  On  reference  to 
the  Figures  of  Plate  11  this  relation  will  be  seen  illustrated,  as  well  as  the  mode 
by  which  the  folds  meet  over  the  dorsal  surface  of  the  embryo  to  form  the  amni- 
otic sac,  which,  when  entirely  closed,  contains  the  amniotic  fluid  separating  the 
envelope  from  the  developing  animal.  While  union  and  fusion  of  the  innermost 
layers  of  the  ecto-mesoclermic  folds  of  the  somatopleure  produce  the  true  am- 
nion with  its  contained  sac  lined  with  ectoderm,  the  separation  of  the  fused 
outer  laminae  of  the  duplicatures  from  the  amniotic  portion  gives  rise  to  a  sec- 
ond externally-lying  envelope,  the  false  amnion,  or  serous  envelope,  in  which 
the  disposition  of  the  component  layers  is  reversed,  since  the  ectoderm  lies  with- 
out, and  the  mesodermic  tissue  next  the  included  space.  The  latter  is  directly 
continuous  with  the  interval  between  the  parietal  and  visceral  laminae  of  the 
cleft  mesoderm,  and  is  the  extra-embryonal  portion  of  the  primitive  body- 
cavity,  which  thus  extends  widely  beyond  the  limits  of  the  embryo  proper. 


DEVELOPMENT  OF  THE   FETAL   MEMBRANES.  Plate  11. 


Embryo. 


1-6.  Diagrams  illustrating  the  formation  of  the  mammalian  fetal  membranes  (modified  from  Roule). 


PHYSIOLOGY   OF  PREGNANCY.  85 

With  the  accumulation  of  the  liquor  amnii  the  amnion  becomes  separated 
from  the  embryo  and  is  pushed  against  the  surrounding  envelopes. 

The  amniotic  fluid,  or  liquor  amnii,  is  a  serous  fluid  produced  probably  by  the 
amnion  itself,  having  a  specific  gravity  varying  from  1.007  to  1.008 ;  it  contains 
from  1.07  to  1.06  per  cent,  of  dry  solids  (Prochownick).  The  amount  of  the 
amniotic  fluid  is  subject  to  great  variation,  the  average  quantity  at  full  term 
being  between  700  and  800  cubic  centimeters,  or  less  than  one  liter.  Not- 
withstanding numerous  investigations,  there  appears  to  exist  no  constant  rela- 
tion between  the  quantity  of  the  amniotic  fluid  and  the  weight  of  the  child  or  of 
the  after-birth.  In  addition  to  the  evident  use  of  the  fluid  for  the  mechanical 
protection  of  the  embryo,  it  is  probable  that  it  affords  a  source  of  water  to  the 
developing  animal,  since  there  is  strong  evidence  to  show  that  the  fluid  is  con- 
tinually swallowed  during  the  latter  part  of  intra-uterine  existence.  Toward 
the  latter  months  of  gestation  the  pressure  induced  by  the  growing  fetus  and 
the  large  amount  of  the  amniotic  fluid  pushes  the  amnion  into  close  contact 
with  the  surrounding  false  amnion,  the  two  becoming  closely,  although  not 
inseparably,  united  by  the  end  of  gestation. 

As  the  embryo  gradually  assumes  a  more  definite  general  form,  the  roots  of 
the  true  amniotic  folds  sink  more  and  more  ventrally  until  they  meet,  thus 
closing  in  the  body-cavity  and  forming  its  anterior  wall.  In  the  early  stages, 
when  the  yolk-sac  or  umbilical  vesicle  communicates  with  the  widely  open 
gut-tract  by  means  of  its  broad  stalk,  approximation  of  the  somatic  plates  is 
prevented.  With  the  decrease  of  the  umbilical  vesicle  and  the  corresponding 
diminution  in  its  stalk  the  ventral  plates  grow  together  and  rapidly  close  the 
pleuro-peritoneal  cavity  except  at  one  point,  the  umbilical  opening,  through 
which  pass  those  structures  that  connect  the  embryo  with  organs  lying  with- 
out its  body,  as  the  atrophic  vitelline  and  allantoic  blood-vessels  and  stalks 
with  their  disappearing  lumina. 

The  Allantois. — The  allantois  appears  as  an  outgrowth  from  the  hind-gut 
(PI.  11,  Figs.  5,  6)  after  the  primitive  digestive  tube  has  become  well  defined 
and  partially  closed.  When  typically  developed  the  allantois  grows  out  as  a 
free  sac  into  the  space  between  the  true  and  the  false  amnion,  rapidly  increasing 
in  size.  In  man,  however,  the  allantois  at  no  time  exists  as  a  free  vesicle, 
since  it  almost  at  once  forms  attachments  with  the  structures  extending  from 
the  caudal  extremity  of  the  human  embryo  as  the  abdominal  stalk  (Fig.  75), 
in  which  is  included  the  lumen  of  the  imprisoned  allantoic  sac. 

The  primary  function  of  the  allantois  is  to  act  as  a  receptacle  for  the  excre- 
tory allantoic  fluids  thrown  off  by  the  Wolffian  bodies,  by  which  primitive 
organs  the  effete,  matters  are  removed  as  by  the  kidneys  at  later  stages.  Sub- 
sequently the  allantois  takes  an  important  part  in  building  up  the  chorion, 
from  which  the  fetal  contribution  to  the  nutritive  apparatus  of  the  placenta  is 
directly  derived. 

The  abdominal  stalk  is  peculiar  to  the  human  embryo,  in  which  it  very 
early  appears  as  a  pedunculated  extension  of  its  caudal  portions  to  the  sur- 
rounding false  amnion,  over  which  it  expands  and  with  which  it  fuse's,  the 


86  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

allantoic  tissue  taking  part  in  the  formation  of  the  chorion  (PI.  12,  Fig.  1). 
The  allantois  in  man,  therefore,  is  never  free,  and  finds  its  expression  in  the 
entodermic  diverticulum,  which  passes  from  the  hind-gut  through  the  abdom- 
inal stalk  toward  the  chorion.* 

Whatever  its  initial  mode  of  formation,  the  allantoic  tissue  grows  with 
rapidity  and  extends  over  the  inner  surface  of  the  false  amnion,  with  -which  it 
soon  becomes  intimately  united,  the  two  membranes  together  constituting  the 
chorion,  a  structure  of  much  importance  in  providing  for  the  nutrition  of  the 
embryo  during  the  last  two-thirds  of  its  intra-uterine  sojourn,  by  reason  of  its 
active  participation  in  the  formation  of  the  placenta. 

The  allantois  being  a  direct  outgrowth  or  evagination  of  the  primitive  gut, 
its  wall  consists  of  an  inner  entodermic  and  an  outer  mesodermic  layer — ex- 
tensions of  the  splanchnopleuric  tissues  forming  the  digestive  tube.  Coinci- 
dentlv  with  the  later  development  of  the  allantois,  blood-vessels  extend  from 
the  arterial  trunks  of  the  embryo  within  the  mesodermic  layer  of  the  sac  and 
invade  this  tissue,  which  has  become  closely  united  with  the  false  amnion  in 
their  joint  production  of  the  chorion. 


Fig.  75.— Diagrammatic  sections  representing  growth  and  arrangement  of  the  amnion  in  the  earliest 
stages  of  the  human  emhryo  (His). 

The  chorion,  covered  with  simple  and  compound  villi,  is  at  first  devoid  of 
blood-vessels,  and  is  composed  of  the  eotodermic  and  entodermic  layers  on  its 
outer  and  inner  surfaces,  between  which  lies  the  thicker  lamella  formed  by  the 
fused  amniotic  and  allantoic  mesodermic  strata.  Shortly  after  the  establish- 
ment of  the  chorion,  the  arteries  conveyed  by  the  allantois  spread  out  within 
the  mesodermic  layer  of  the  chorion  and  invade  the  villi,  which  then  display 
vascular  loops  within  their  characteristic  leaf-like,  club-shaped  processes. 
These  processes  often  consist  of  a  main  primary  stalk  from  which  second- 
ary twigs  branch,  from  which  diverge  the  ultimate  leaves. 

^JThe  term  "chorion"  is  here  used  in  a  restricted  sense  as  indicating  the  membrane 
resulting  from  the  fusion  of  the  false  amnion  and  the  allantoic  tissue ;  by  some  authors 
the  ''chorion"  represents  the  entire  extra-embryonic  somatopleure,  which  gives  rise  alike  to 
the  true  and  the  false  amnion. 


DEVELOPMENT  OF  THE  FETAL  MEMBEANES.  Plate  12. 


Vascular  villi  of 
placental  chorion. 


I  'itelline  vesicle. 


Allantoic  blood-vessels. 


Allantoic  stalk. 


1,  2.  Diagrams  illustrating  the  later  stages  of  the  formation  of  the  mammalian  fetal  membranes 
(modified  from  Roule). 


PHYSIOLOGY   OF  PREGNANCY.  87 

The  form  and  arrangement  of  the  villi  vary  somewhat  with  the  duration 
of  pregnancy:  at  the  third  month,  or  when  the  placenta  is  formed,  the  villi  are 
short,  thick-set,  and  of  irregular  shape ;  later  they  become  less  irregular,  and 
the  secondary  branches  leave  the  parent  stems  less  acutely;  finally,  at  full 
term,  the  villi  are  more  regularly  disposed  and  their  branches  have  become 
long  and  slender  and  less  closely  set.  The  recognition  of  the  villi  of  the  cho- 
rion is  often  a  matter  of  much  practical  importance,  since  their  presence,  as 
determined  by  microscopical  examination  of  suspicious  matters  discharged  per 
vaginam,  is  positive  evidence  of  the  existence  of  pregnancy.  Their  peculiar 
arrangement,  and  their  flattened,  petal-like  form,  together  with  their  vascular 
connective-tissue  stroma  and  epithelial  covering,  usually  suffice  to  establish  the 
diagnosis. 

The  Placenta  and  Deciduce. — The  primary  uses  of  mechanical  protection 
afforded  by  the  membranes  in  mammalian  embryos  are  supjfleruented  by  the 
important  role  of  assisting  in  establishing  an  efficient  nutritive  organ  through 
which  the  maternal  tissues  may  extend  the  necessary  aid  to  the  maintenance  of 
the  developing  animal  during  the  latter  two-thirds  of  its  intra-uterine  life. 
Such  oi'gan  is  the  placenta,  in  whose  production  both  fetal  and  maternal  struct- 
ures take  an  active  part. 

The  early  villi  of  the  chorion  are  practically  identical  in  all  parts  where 
developed.  Very  soon,  however,  the  villi  occupying  the  area  which  later  will 
correspond  with  that  of  the  placenta  exhibit  unusual  growth,  and  outstrip  in 
size  aud  vigor  those  of  the  remaining  parts  of  the  envelope.  This  difference 
in  the  development  of  the  villi  marks  the  division  of  the  membrane  into  the 
chorion  frondosum  and  the  chorion  losve,  the  former  being  that  part  of  the 
chorion  which  contributes  the  fetal  portion  of  the  placenta  (Fig.  76).  The 
villi  of  the  chorion  lseve  undergo  gradual  atrophy  and  finally  disappear. 

The  fertilized  ovum  on  reaching  the  uterus,  after  descending  the  oviduct, 
becomes  entangled  and  retained  within  the  folds  of  the  soft,  thickened  mucous 
membrane  prepared  for  its  reception.  Immediately  after  its  lodgement,  which 
is  usually  in  the  vicinity  of  the  fundus,  the  ovum,  according  to  the  recent 
studies  of  Peters,  erodes  the  uterine  lining,  sinks  beneath  the  surface,  and 
becomes  embedded  within  the  subepithelial  tissue  of  the  mucous  membrane, 
the  orifice  of  entrance  becoming  closed.  Thus  encapsulated,  the  ovum 
rapidly  increases  in  size,  with  the  result  that  the  overlying  hypertrophied 
mucous  membrane  becomes  elevated  and  projects  into  the  uterine  cavity  as 
the  decidua  reflexa. 

In  view  of  the  fact  that  the  mucosa  of  the  uterus  is  discarded  at  the  close 
of  labor,  the  thickened  uterine  lining  is  appropriately  termed  the  decidua;  of 
this  membrane  three  regions  are  recognized  :  the  decidua  reflexa,  or  that  por- 
tion which  encloses  the  ovum  by  the  reflected  folds ;  the  decidua  vera,  or  that 
portion  which  constitutes  the  greater  part  of  the  general  lining  of  the  uterine 
cavity  ;  and  the  decidua  serotina,  or  that  portion  of  the  uterine  lining  included 
within  the  embryonic  sac  completed  by  the  reflexa  (Fig.  76;  PI.  13).  The 
decidua  serotina  derives  especial  significance  from  the  fact  that  it  contributes 
the  maternal  part  in  the  formation  of  the  placenta. 


88  A3IEBICAN   TEXT-BOOK    OF    OBSTETRICS. 

The  changes  affecting  the  maternal  tissues  consist  primarily  in  proliferation 
of  the  epithelium  and  the  glands,  the  latter  becoming  greatly  enlarged  both  in 
size  and  in  the  number  of  the  tubules,  the  increase  particularly  involving 
their  deeper  parts.  Subsequently  the  pressure  exerted  upon  this  hypertro- 
phied  tissue  by  the  rapidly  growing  embryo  and  its  surrounding  structures 
induces  atrophy  and  degeneration,  so  that  the  outermost  part  of  the  thickened 
uterine  mucosa  becomes  the  stratum  compactum,  and  the  middle  part  the  stra- 
tum spongiosum  (Fig.  77).  The  limited  zone  embracing  the  fundi  of  the  tubular 
uterine  glands  remains  unaffected,  and,  after  the  expulsion  of  the  structures 


Fig.  76.— Diagram  illustrating  relations  of  structures  of  the  human  uterus  at  the  end  of  the  seventh 
week  of  pregnancy  (modified  from  Allen  Thompson). 

constituting  the  after-birth,  institutes  the  processes  of  repair  by  which  the  new 
mucous  membrane  of  the  uterus  is  produced.  As  the  result  of  the  penetra- 
tion of  the  ovum  into  the  subepithelial  portions  of  the  uterine  mucosa  the 
vascular  chorionic  villi  are  brought  into  close  relations  with  the  vascular 
connective  tissue  of  the  uterus,  by  which  the  interchanges  between  the  fetal 
and  maternal  circulations  are  facilitated. 

The  relations  between  the  fetal  and  the  maternal  structures,  in  placental  of 


RELATIONS  OF   FETUS   AND   DECIDUJE. 


Plate  13. 


PHYSIOLOGY   OF  PREGNANCY.  89 

the  simplest  type  such  as  possessed  by  the  hog,  consist  essentially  in  the  recep- 

X  v 


Fig.  77.— Section  through  uterine  wall  and  attached  placenta  (Wagner) :  u,  uterine  wall  rendered 
spongy  by  greatly-developed  uterine  sinuses  (us) ;  iia,  branches  of  uterine  artery ;  ds,  decidua  serotina ;  s, 
line  of  separation ;  fp,  fetal  portion  of  placenta,  consisting  of  a  mass  of  vascular  fetal  villi  (v.v.v.),  sur- 
rounded by  the  maternal  blood-sinuses ;  am,  amnion  covering  free  internal  surface  of  placenta. 

tion  of  the  simple  chorionic  villi  within  corresponding  depressions  in   the 
maternal  tissues,  the  circulation  of  the  villi  coming  into  close  approximation 


Fig.  78.— Placenta  viewed  from  uterine  surface  of  attachment,  showing  divisions  into  cotyledons  (Bidloo). 

with   the  enlarged  blood-vessels   of   the   mother.      These   simple   relations 
become  complicated  in  the   higher  mammals  and  in  man  by  the  complex 


90 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


character  of  the  chorionic  villi,  whose  irregular  form  and  disposition  are 
further  masked  by  actual  attachments  formed  between  the  tips  of  many 
large  villi  and  the  maternal  tissue  (PI.  14). 

The  exterior  of  the  early  human  ovum,  using  the  latter  term  as  indicat- 
ing the  embryo  with  its  investing  membranes,  is  covered  with  villous  pro- 
jections composed  of  the  proliferating  epithelium  derived  from  the  ectoderm 
of  the  primitive  chorion  ;  this  layer  rapidly  acquires  considerable  thickness 
and  sends  its  projections  into  the  surrounding  maternal  tissue,  thereby,  even 
at  a  very  early  stage,  becoming  an  active  agent  in  securing  nutritive  mate- 
rials for  the  young  embryo.  This  ectodermic  envelope  has  received  the 
name  of  trophoblast  in  recognition  of  its  important  nutritive  function. 


Fig.  79.— Placenta  at  full  term,  showing  superficial  distribution  of  blood-vessels  (Minot). 

Coincidently  with  the  changes  affecting  the  decidua  serotina,  the  capil- 
lary blood-vessels  of  this  part  of  the  uterine  mucous  membrane  undergo 
enormous  expansion,  so  that,  finally,  they  are  converted  into  the  large  and 
conspicuous  blood-spaces  occupying  the  intervals  between  the  attached  cho- 
rionic villi  and  the  adjacent  maternal  tissue.  These  intervillous  blood-spaces, 
the  enormously  dilated  maternal  capillaries,  are  supplied  by  arterial  twigs 
and  are  drained  by  corresponding  venous  trunks  connected  with  the  larger 
uterine  vessels.     Notwithstanding  the  attachment  of  many  large  villi,  the 


DEVELOPMENT  OF  THE  FETUS  AND   ITS   APPENDAGES.     Plate  14. 


55  'H    fr 


PHYSIOLOGY  OF  PREGNANCY. 


91 


greater  number,  comprised  by  the  smaller  villi,  are  not  so  bound  clown,  their 
free  ends  floating  within  the  large  lakes  of  maternal  blood,  from  which  they 
'  are   separated  by   the   attenuated  and  atrophic   remains  of  the   ectodermic 
trophoblast,  now  known  as  the  syncytium. 

The  human  placenta  at  full  term,  as  seen  after  the  expulsion  of  the  after- 
birth, is  a  discoidal  mass,  usually  oval,  sometimes  circular,  but  often  irregular 
in  outline,  about  18  centimeters  in  diameter  and  2.5  to  3  centimeters  in  thick- 
ness. It  presents  an  inner  smooth  surface,  covered  by  the  amnion  and  look- 
ing toward  the  fetus,  and  an  outer  rough,  spongy,  uterine  surface  of  attach- 
ment subdivided  by  furrows  into  numerous  more  or  less  distinct  areas  or 
cotyledons  (Fig.  78)  composed  of  the  lacerated  decidual  tissue  and  vessels  torn 
through  at  the  time  of  the  separation  of  the  placenta,  the  decidua  serotina  split- 
ting, one  part  adhering  to  the  outer  surface  of  the  placenta,  the  other  remaining 
attached  to  the  uterine  wall.  In  contrast  with  the  dark  blood-clot  hue  of  this 
tissue,  the  smooth,  shining  amniotic  surface  appears  of  a  generally  lighter, 
somewhat  mottled  tint,  made  up  of  reddish-gray  patches  alternating  with 
yellowish  areas,  which  depend  respectively  upon  the  contained  blood  and  the 
fetal  villi,  whose  colors  shine  through  the  superimposed  transparent  amnion. 

The  placental  blood-vessels  (Fig.  79) — the  two  umbilical  arteries  and  the 
single  umbilical  vein — spread  out  in  all  directions  from  the  usually  eccen- 
tric point  of  insertion  of  the  umbilical  cord,  when  distended  with  blood  their 
courses  being  readily  traced  both  by  sight  and  by  touch  beneath  the  overlying 
amnion.  The  arterial  twigs  are  more  superficial  than  the  veins,  which  are 
considerably  larger  in  diameter.  Both  sets  of  vessels  pass  from  the  smaller 
to  the  larger  twigs  without  anastomoses. 

Structure. — If  the  freshly-cut  surface  of  the  thickness  of  the  placenta  be 
carefully  examined  with  the  unaided 
eye  or  with  a  low  magnifying  glass,  the 
entire  organ  is  seen  to  be  composed  of 
an  inner  and  an  outer  membranous 
boundary,  between  which  is  included  a 
thick  spongy  layer  contributing  almost 
the  entire  thickness  of  the  organ.  Closer 
investigation  shows  that  the  spongy 
layer  is  composed  of  the  loosely  held 
masses  of  chorionic  villi  (Fig.  80),  with 
the  intervillous  blood-spaces,  separated 
into  the  cotyledonous  areas  by  con- 
nective-tissue septa.  The  outer  mem- 
branous boundary  consists  of  the  con- 
densed portion  of  the  decidua  serotina, 
which  adheres  to  the  fetal  villi  and  sup- 
plies the  outer  wall  to  the  blood-spaces  ; 
the  inner  boundary  includes  the  denser  portion  of  the  chorion  together  with 
the  adherent  amnion. 

Microscopic  examination  of  the  spongy  placental  tissue,  as  seen  in  sections 


>0.— Portion  of  injected  villus  from  a  pla- 
centa of  about  five  months  (Minot). 


92  AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 

(Figs.  81,  82),  shows  the  villi,  although  differing  greatly  in  size,  to  be  made 


Fig.  SI —Section  through  placenta  of  seven  months  in  situ  (Minot) :  Am,  amnion;  Clio,  chorion;  Yi, 
root  of  a  villus ;  vi,  sections  of  ramifications  of  the  villi  among  the  maternal  blood-spaces  ;  D,  deep  layer 
of  the  decidua,  showing  remains  of  enlarged  glands  of  stratum  spongiosum;  IV,  uterine  blood-vessel 
connected  with  placental  sinus  ;  Mc,  muscular  wall  of  uterus. 

up  of  a  stroma  of  embryonal  connective  tissue  containing  large  branched  cells 


PHYSIOLOGY    OF  PREGXAXCY. 


93 


and  blood-vessels ;  these  latter  consist  of  the  larger  twigs,  encased  by  the 
robust  primary  stalks,  and  of  all  gradations  of  size  to  the  slender  capillary 
loops  supplying  the  terminal  petal-like  processes.  The  exterior  of  the  very 
voting  chorionic  ectodermic  villi  is  covered  by  a  layer  of  epithelium,  to 
which  reference  has  already  been  made  as  the  trophoblast.  "With  the  pro- 
gressive intimacy  between  the  latter  and  the  maternal  tissue,  the  trophoblast 


tio&H 


Fig.  82.— A,  section  through  margin  of  placenta  at  full  term  (Minot):  D,  D,  deep  layer  of  decidua; 
Vi,  chorionic  villi  variously  cut,  blood-vessels  injected ;  Si,  marginal  space  nearly  free  from  villi ;  vi, 
atrophic  extra-placental  villi;  Clio,  chorion;  6,  vessel  of  uterine  wall;  Fib,  canalized  fibrine  derived 
from  modified  chorionic  ectoderm.  B,  decidual  tissue  from  placenta  at  full  term :  d,  d',  decidual  cells ; 
v,  blood-vessel. 

undergoes  marked  change  and  diminution  due  to  the  encroachment  of  the 
rapidly  invading  blood-vessels  of  the  uterine  mucous  membrane.  Owing  to 
the  action  of  the  maternal  blood-stream,  according  to  Peters,  the  trophoblast 
bordering  the  vascular  spaces  becomes  converted  into  a  modified  stratum,  the 
syncytium,  the  origin  of  which  must  be  referred,  therefore,  to  the  fetal  tis- 
sues. When  examined  in  section,  about  the  fourth  month,  the  placental  villi 
possess  an  ectodermic  envelope  consisting  of  two  layers,  an  inner,  composed 
of  low  cuboidal  epithelial  elements,  nucleated  and  well  defined  ;  and  an 
outer  stratum,  the  syncytium,  which  appears  as  a  protoplasmic  layer  in 
which  lie  numerous  nuclei,  but  no  well-defined  cell  boundaries. 

Sections  of  the  placenta  during  the  later  months  of  gestation  fail  to  reveal 
any  definite  endothelial  partition  between  the  exterior  of  the  villi  and  the 
maternal  blood-spaces,  the  villi  seemingly  coming  directly  in  contact  with  the 
blood  of  the  mother.     The  determination  of  the  existence  or  absence  of  a  dis- 


94  AMERICAN   TEXT-BOOK   OE    OBSTETRICS. 

tinct  wall  to  the  blood-space  has  given  rise  to  much  discussion  and  conflicting  as- 
sertion. The  solution  of  the  question,  as  so  often  is  the  case,  seems  to  be  found 
in  the  more  careful  study  of  the  development  of  the  tissues,  which  study  has 
shown  that  in  the  earliest  stages  the  fetal  villi  are  separated  from  the  maternal 
blood-vessels  by  an  intervening  layer  of  decidua  as  well  as  by  the  endothelium 
of  the  vessels.  With  the  progressively  increasing  capacity  of  the  blood- 
capillaries  the  compression  and  atrophy  of  the  interposed  structures  follow, 
during  the  later  months  of  pregnancy  the  external  surface  of  the  chorion  and 
its  villi,  covered  by  the  syncytium,  constituting  the  immediate  wall  of  the 
maternal  blood-space. 

4.  Umbilical  Cord. — The  formation  of  the  human  umbilical  cord  is 
closely  related  to  the  primary  abdominal  stalk.  The  latter,  as  already  noted, 
may  be  regarded  as  the  extension  of  the  embryo — as  a  sort  of  pedicle  connect- 
ing its  caudal  parts  with  the  chorion  and  containing  the  allantoic  diverticulum. 
In  the  early  stages  the  somatic  folds  which  form  the  amnion  bear  the  same 
relation  to  the  abdominal  stalk  as  they  do  to  the  more  anterior  parts  of  the 
embryo ;  later  they  bend  around  the  stalk  to  meet  and  join  on  its  ventral 
surface,  the  amnion  in  consequence  becoming  separated  from  the  stalk,  which 
thus  becomes  gradually  enclosed  within  a  tubular  amniotic  sheath.  The  closure 
of  the  somatopleuric  folds  around  the  abdominal  stalk  imprisons  the  umbilical 
or  vitelline  duct  within  a  space  which  is,  in  fact,  part  of  the  celom.  This  space 
soon  becomes  greatly  reduced,  and  finally  is  obliterated.  The  foregoing  rela- 
tions point  out  the  fact,  strongly  emphasized  by  Minot,  that  the  umbilical  cord 
is  covered  with  the  direct  extension  of  the  embryonic  somatopleure,  and  not 
with  the  amnion,  as  is  often  asserted,  since  the  amnion  gradually  becomes  sepa- 
rated from  the  embryo  along  the  cord  as  far  as  its  distal  end,  where  it  still 
remains  connected. 

The  most  important  constituents  of  the  umbilical  cord  in  its  earlier  con- 
dition are  the  two  umbilical  arteries,  the  two  umbilical  veins,  the  allantoic 
diverticulum,  and  the  extension  of  the  celom  containing  the  vitelline  duct  and, 
possibly,  traces  of  the  vitelline  vessels.  Later,  the  umbilical  veins  fuse  and 
constitute  a  single  vessel ;  the  allantoic  lumen  and  the  celomic  space  atrophy 
and  disappear.  The  atrophic  vitelline  or  umbilical  duct  long  remains,  even 
after  birth  the  vesicle  and  its  duct  appearing  as  a  minute  sac  and  stalk  lying 
between  the  amnion  and  the  chorion,  in  close  proximity  to  the  placenta. 

The  human  umbilical  cord  at  birth  measures  about  55  centimeters  (22  inches) 
in  length,  with  from  15  to  160  centimeters  (6  to  64  inches)  as  the  extremes  of 
its  variations;  its  diameter  is  from  10  to  15  millimeters  (|  to  f  inch).  The 
cord  usually  joins  the  inner  smooth  surface  of  the  placenta  eccentrically,  its 
insertion  at  times  being  marginal,  or,  in  rarer  cases,  even  altogether  outside  the 
immediate  area  of  the  placenta.  The  apparent  twisted  condition  of  the  cord  is 
often  very  marked,  the  spirals,  sometimes  to  the  number  of  thirty  or  more, 
being  emphasized  by  the  contained  blood-vessels.  While  this  phenomenon  has 
long  been  known,  a  satisfactory  explanation  of  the  twisted  appearance,  which 
begins  before  the  third  month,  still  remains  to  be  given,  notwithstanding  nu- 
merous theories  and  discussions.     A  point  of  especial  interest,  as  pointed  out 


PHYSIOLOGY    OF   PREGNANCY. 


95 


by  Minot,  is  that  there  is  no  evidence  that  the  entire  cord  really  undergoes 
torsion,  but  rather  that  the  blood-vessels  become  coiled  within  the  soft  tissue 
as  the  result  of  an  excessive  unequal  growth  still  insufficiently  understood. 

The  structure  of  the  cord  includes  an  external  covering  of  epithelium 
directly  continuous  at  its  distal  end  with  that  of  the  amnion.  The  bulk  of 
the  cord  consists  of  the  peculiar  form  of  embryonal  connective  tissue  known  as 
the  jelly  of  Wharton,  rich  in  branched  cells  with  anastomosing  protoplasmic 
processes.  Shortly  beyond  the  umbilical  opening  both  capillaries  and  nerves 
are  apparently  wanting;  lymphatics,  in  the  sense  of  definite  canals,  are  also 
absent.  In  addition  to  the  large  umbilical  blood-vessels,  epithelial  masses 
indicate  the  remains  of  the  allantoic  diverticulum  and  the  vitelline  duct. 

5.  Development  of  the  External  Form. — Adoptingthedivisions  suggested 
by  His,  it  is  convenient  to  distinguish  three  stages  in  the  development  of' the 
human  subject.  The  blastodermic  stage  embraces  the  first  two  weeks  of  gesta- 
tion, and  is  occupied  by  the  earliest  developmental  processes ;  the  embryonal 
stage  includes  from  the  third  to  the  fifth  week,  during  which  time  the  charac- 
teristic embryonal  features  are  pronounced  and  the  principal  organs  and 
symptoms  are  well  established;  the  remaining  weeks  of  pregnancy  are  devoted 
to  the  fetal  stage,  during  which  the  embryonal  characters  are  gradually  replaced 
by  those  of  the  fetus  and  the  full-term  child.  While  it  is  evident  that  no 
sharp  demarcation  separates  these  stages,  yet  certain  well-pronounced  charac- 
teristics distinguish,  in  general  at  least,  embryos  of  particular  developmental 
epochs,  and  consequently  serve  to  determine  their  probable  age  notwithstanding 
individual  variation. 

Stage  of  the  Blastoderm. — Opportunities  for  examining  early  human  blas- 
todermic vesicles  are  rare.  One  of  the  youngest  well-authenticated  specimens 
is  the  classical  ovum  of  about  twelve  days  described  by  Reichert  (Fig.  83).   The 


Fig.  83.— Human  ovum  of  about  twelve  days  (Eeichert) :  A,  side  view  ;  B.  front  view.    The  villi  are  seen 
pto  be  limited  in  distribution,  leaving  the  poles  free. 

appearance  of  this  ovum  emphasizes  the  early  and  precocious  development  of 
the  villi  which  encircle  the  flattened  lenticular  vesicle  (5.5  millimeters  in  its 
greatest  diameter  by  3.3  millimeters  in  thickness)  as  a  closely  set  equatorial 
zone.  Of  the  embryo  proper  no  trace  was  discoverable,  a  patch  of  thickened 
cells  alone  representing  the  embryonal  area.  The  earlier  processes  of  seg- 
mentation and  blastnlation  have  never  been  observed  in  the  human  ovum. 
Stage  of  the  Embryo. — The  thirteenth  and  fourteenth  days  witness  the 
evolution  of  the  early  embryonal  form  as  effected  by  the  development  of  the 


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AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


medullary  groove  and  canal  and  their  cephalic  expansion.  The  embryo  is 
attached  by  the  allantoic  stalk  to  the  surrounding  membranes,  the  axes  of  the 
stalk  and  the  upright  embryo  generally  coinciding  (Figs.  84,  85 ;  see  also  Fig. 
97) ;  what  flexure  exists  at  this  time  is  backward,  and  results  in  a  concave  dor- 
sal outline.  The  ventral  aspect  of  the  embryo  of  this  stage  is  largely  occupied 
by  the  relatively  huge  vitelline  sac,  which  freely  communicates  with  the  imper- 
fectly defined  gut  along  almost  the  entire  length  of  the  embryo.  The  preco- 
ciously developed  amnion  has  completely  enveloped  the  enibryo  and  its  stalk 
as  far  as  the  distal  attachments  of  the  latter.  The  heart  is  first  represented 
by  two  longitudinal  folds  corresponding  with  the  primary  halves  from  which 


Fig.  S4.— Human  embryo  of  about  the  fifteenth  day  (His) :  the  embryo  is  attached  to  the  wall  of  the 
blastodermic  vesicle  by  means  of  the  belly  or  allantoic  stalk,  and  is  enclosed  within  the  amnion ;  the 
large  vitelline  sac  freely  communicates  with  the  still  widely  open  gut. 

the  organ  is  formed  ;  slightly  later,  these  folds  fuse  into  a  single  heart,  which 
then  appears  as  a  conspicuous  projection  between  the  yolk-sac  and  the  cephalic 
vesicle. 

The  third  week  (Fig.  86)  is  productive  of  many  important  additions  to  the 
exterior  of  the  embryo.  Its  form  becomes  more  definite ";  the  brain-vesicles, 
together  with  the  optic  vesicles  and  the  auditory  sacs,  are  differentiated ;  the" 
visceral  arches  and  the  corresponding  furrows  are  formed  ;  the  yolk-sac  is  much 
more  constricted,  and  its  narrower  connection  with  the  gut  foreshadows  the 
later  vitelline  stalk.  During  the  twenty-first  clay  the  first  rudiments  of  the 
limbs  appear. 

The  fourth  week  (Fig.  86)  is  marked  by  great  increase  in  size  and  by  con- 
spicuous changes  which  give  to  embryos  of  this  age  distinctive  features,  growth 
being  relatively  more  active  at  this  period  than  at  any  other.  At  the  termination 


PHYSIOLOGY    OF  PREGNANCY. 


97 


of  the  third  week  the  embryo  is  still  erect.  During  the  next  day  flexion  takes 
place  with  great  rapidity,  so  that  during  the  twenty-third  day  the  cephalic  and 
caudal  poles  of  the  embryo  actually  meet  or  even  overlap,  the  dorsal  outline 
approximating  a  circle  (Figs.  86,  87).  The  individual  brain-vesicles  are  better 
developed,  as  are  also  the  visceral  arches  and  furrows,  the  eyes,  ears,  and  nose  ; 
the  heart  has  increased  in  size,  and  the  limb-buds  have  become  more  pro- 
nounced. At  the  end  of  the  twenty-third  day  extreme  flexion  has  taken  place, 
from  which  time  until  the  close  of  the  fourth  week  the  embryo  gradually 
becomes  less  tightly  coiled  on  itself,  the  larger  and  more  conspicuous  head 
slowly  rising  and  leaving  the  tail. 

During  the  latter  half  of  the  fourth  week,  in  addition   to  the  increased 
development  of  the  visceral  arches,  the  individual  cephalic  flexures  become 


Fig.  85.— Human  embryo  of  about  the  thirteenth  day  (His) :  the  caudal  pole  of  the  embryo  is  con- 
nected with  the  blastodermic  vesicle  by  means  of  the  abdominal  or  allantoic  stalk;  the  amnion  already 
completely  encloses  the  embryo,  and  the  large  vitelline  sac  communicates  throughout  the  greater  part 
of  the  mitral  surface  by  means  of  the  unclosed  gut-tract. 

very  conspicuous.  These  flexures  consist  of  a  sharp  bending  of  the  ante- 
rior parts  of  the  head  upon  the  posterior  half,  resulting  in  a  change  of 
nearly  90°  in  the  cephalic  axis,  with  the  production  of  a  conspicuous 
prominence  marking  the  position  of  the  mid-brain.  Posteriorly,  the  cervical 
flexure  sharply  indicates  the  junction  of  the  cephalic  and  trunk  segments; 
farther  caudally,  the  dorsal  and  coccygeal  flexures  mark  less  pronounced 
changes  in  the  direction  of  the  embryonic  axis.  On  either  side  of  the  dorsal 
mid-line,  extending  from  the  cervical  flexure  to  the  tip  of  the  caudal  extremity, 
a  series  of  prominent  quadrilateral  areas  indicate  the  position  of  the  somites  or 
provertebra?  (Fig.  86,  11  and  12). 

The  development  of  the  visceral  arches  reaches  its  highest  expression  by  the 


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AMERICA!?   TEXT-BOOK    OF    OBSTETRICS. 


termination  of  the  fourth  week,  when  the  series  of  arches  is  seen  in  its  best  condi- 
tion (see  Fig.  129).  In  man  andin  mammals  fivearchesare  successively  developed 
from  before  backward,  the  last,  however,  being  scarcely  differentiated  and  very 
inconspicuous.  The  first  arch  when  fully  formed  is  partially  divided  into  an 
upper  and  a  lower  secondary  division,  the  maxillary  and  mandibular  p'ocesses, 


'■^  J' 


so  called  from  the  parts  to  whose  construction  they  respectively  largely  con- 
tribute. The  maxillary  processes  of  the  first  arch,  in  connection  with  the  inter- 
vening naso-frontal  process,  contribute  the  parts  which  eventually  become  the 
upper  boundaries  of  the  oral  cavity ;  the  mandibular  processes  of  the  same 
arch  join  to  form  the  lower  boundary  of  the  mouth.  During  the  fifth  week 
the  margins  of  the  centrally  projecting  naso-frontal  plate  differentiate  into  two 


PHYSIOLOGY   OF  PREGNANCY. 


99 


secondary  processes,  the  processus  globulares,  forming  the  inner  borders  of  the 
nasal  pits,  and  the  lateral  frontal  processes,  which  contribute  the  outer  wall  of 
the  nasal  fossa?  and  separate  these  depressions  from  the  eyes.  These  processes 
normally  unite  co  form  the  continuous  structures  around  the  nose  and  the 
mouth. 

Faulty  union  or  imperfect  closure  of  the  intervening  fissures  gives  rise  to 
the  varieties  of  hare-lip  and  cleft  palate  and  to  other  forms  of  congenital  facial 
defects.  The  second  or  hyoid  arch,  as  well  as  the  third,  fourth,  and  fifth 
arches,  eventually  fuses  with  its  neighbors  and  loses  its  identity ;  a  similar 
fate  awaits  the  intervening  outer  visceral  furrows  or  "  clefts,"  with  the  excep- 


Fig.  87.— Development  of  the  face  of  the  human  embryo  (His) :  A,  embryo  of  about  twenty-nine  days. 
The  naso-frontal  plate  differentiating  into  processus  globulares,  toward  which  the  maxillary  processes 
of  first  visceral  arch  are  extending.  B,  embryo  of  about  thirty-four  days  :  the  globular,  lateral,  frontal, 
and  maxillary  processes  are  in  apposition ;  the  primitive  opening  is  now  better  defined.  C,  embryo  of 
about  the  eighth  week :  immediate  boundaries  of  mouth  are  more  definite  and  the  nasal  orifices  are 
partly  formed,  external  ear  appearing.    D,  embryo  at  end  of  second  month. 

tion  of  the  first,  since  they  gradually  become  obliterated  by  the  fusion  of  the 
surrounding  arches.  The  first  outer  furrow,  or  hyomandibular  cleft,  contrib- 
utes largely  to  the  formation  of  the  external  auditory  canal,  while  the  sur- 
rounding portions  of  the  mandibular  and  hyoid  arches  contribute  the  tissue 
from  which  the  external  ear  is  derived. 


100 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


The  Second  Month.— The  fifth  and  sixth  weeks  (Figs.  86,  88)  add  to  the  size 
and  the  general  advanced  development,  although  the  phenomenal  rate  of  growth 
of  the  preceding  week  is  replaced  by  more  gradual  increase.  The  limbs  con- 
stitute the  most  characteristic  features  of  this  period,  since  what  prior  to  the 
fifth  week  were  but  rudimentary  limb-buds  now  undergo  differentiation  into 
distinct  segments,  at  first  two,  then  three.  Toward  the  close  of  the  fifth  week 
the  flattened  terminal  segments  representing  the  future  hands  and  feet  exhibit 
distinctions  as  thin  marginal  plates  and  thicker  proximal  portions.  The 
marginal  areas  very  soon  exhibit  traces  of  the  digits  as  small  elevations 
separated  by  shallow  grooves  which  gradually  extend  toward  the  free  ends. 
The  fore  limbs  appear  slightly  earlier 
than  the  hind  limbs,  and  retain  this  lead 
throughout  their  development.  By  the 
middle  of  the  sixth  week  the  fingers 
are  sufficiently  developed  to  project  be- 
yond the  hand,  although  the  toes  are 


Fig.  SS.— Human  embryo  of  about  sis  weeks, 
enlarged  five  times  (His). 


Fig.  89.— Human  embryo  of  about  seven  weeks, 
enlarged  five  times  (His). 


just  beginning  to  be  outlined,  and  represent  a  stage  of  ten  to  fourteen  days 
later.  Coincidently  with  these  changes  the  general  development  of  the  embryo 
has  steadily  progressed  (Fig.  89),  with  the  result  of  supplanting  the  embryonal 
characteristics  by  those  of  distinctly  fetal  type.  The  head,  though  propor- 
tionately large,  has  become  partially  once  more  raised  ;  the  boundaries  of  the 
mouth  have  become  definitely  located  ;  the  external  parts  of  the  eye,  the  ear, 
and  the  nose  are  well  advanced  ;  and  the  general  contour  of  the  trunk  has 
assumed  more  of  the  characters  of  the  child. 

The  second  month  witnesses  the  disappearance  of  the  cervical  flexion  and 


PHYSIOLOGY   OF  PREGNANCY. 


101 


the  further  lifting  of  the  head,  which  is  still  very  large  (Fig.  90).  The  face 
shows  distinct  advancement  toward  its  completed  type,  although  the  nose  is  yet 
unduly  broad,  and  indications  of  the  fissures  surrounding  the  mouth  are  dis- 
cernible. The  limbs  project  from  the  body,  and  the  fingers,  including  the 
differentiated  thumb,  and  the  toes  are  well  defined.    By  the  close  of  the  second 


Fig-  90.— Human  embryo  of  about  eight  and  a  half  weeks,  enlarged  five  times  (His). 

month  the  fetus  measures  from  25  to  30  millimeters  (1  to  If  inches)  in  length 
and  weighs  from  15  to  20  grams. 

The  Third  Month.— The  third  month  establishes  the  human  form,  although 
the  head  still  unduly  preponderates.  The  limbs  have  acquired  their  definite 
shape,  and  the  imperfect  nails  are  present  on  both  fingers  and  toes.  During 
this  month  the  external  organs  of  generation  become  definitely  differentiated, 


102  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

although  they  make  their  appearance  several  weeks  earlier.  At  the  end  of 
this  period  the  fetus  measures  about  7  centimeters  (2f  inches)  in  length  and 
weighs  about  120  grams  (4  ounces). 

The  Fourth  Month. — Short  hairs,  devoid  of  pigment,  appear  on  the  scalp 
and  on  some  other  parts  of  the  body,  which  is  now  covered  with  firmer  skin 
of  rosy  hue.  The  eyelids,  nostrils,  and  lips  are  closed.  The  anus  opens,  and 
the  coils  of  intestine,  which  before  extended  into  the  umbilical  cord,  now  lie 
entirely  within  the  abdominal  cavity.  The  point  of  emergence  of  the  umbil- 
ical cord  lies  low  down,  close  to  the  pubes.  The  head  forms  about  one-fourth 
of  the  entire  body ;  the  bones  of  the  skull,  while  ossifying,  are  still  widely 
separated.  The  sexual  distinctions  of  the  external  organs  are  well  defined.  At 
the  end  of  this  period  the  length  of  the  fetus  has  increased  to  about  12.5  cen- 
timeters (5  inches),  and  its  weight  to  between  230  and  240  grams  (7f-  ounces). 

The  Fifth  Month. — The  heart  and  the  liver  share  with  the  head  in  the  undue 
preponderance  which  these  parts  present.  The  contents  of  the  small  intestine — 
the  meconium — show  traces  of  bile,  being  of  a  pale  yellowish-green  color.  The 
lower  extremities  are  now  longer  than  the  arms ;  the  nails  are  well  formed. 
Hairs  are  more  plentiful,  but  are  devoid  of  color.  At  the  termination  of  this 
month  the  fetus  measures  20  centimeters  (8  inches)  in  length  and  weighs  about 
500  grams  (1  pound).   The  fetal  movements  are  now  distinctly  felt  by  the  mother. 

The  Sixth  Month. — The  surface  presents  many  wrinkles  and  a  dirty-reddish 
hue ;  the  sebaceous  coating,  the  vernix  caseosa,  begins  to  appear.  This  whitish 
substance  is  composed  of  the  dead  and  shed  surface-epithelium,  mingled  with 
the  secretions  of  the  sebaceous  glands  ;  its  primary  function  is  the  protection  of 
the  fetal  integument  from  maceration  by  the  amniotic  fluid.  Eyebrows  and 
eyelashes  begin  to  grow.  The  length  of  the  fetus  by  the  end  of  this  period  has 
increased  to  30  centimeters  (12  inches),  and  its  weight  to  about  1  kilogram  or 
1000  grams  (2  pounds). 

The  Seventh  Month. — The  continued  deposition  of  subcutaneous  fat  causes 
a  general  appearance  of  greater  plumpness,  although  the  surface  is  still  some- 
what wrinkled  ;  hairs  about  5  millimeters  (T3g-  inch)  in  length  ;  eyelids  are  now 
permanently  open.  The  liver  is  still  relatively  large ;  meconium  occupies  the 
entire  large  intestine  ;  the  testicles  have  descended  as  far  as,  or  even  into,  the 
inguinal  canals.  Children  born  at  the  end  of  this  period  may  survive, 
although  they  usually  succumb.  The  fetus  now  measures  about  35  centi- 
meters  (14  inches)  and  weighs  about  1J  kilograms  (3  pounds). 

The  Eighth  Month. — This  and  the  succeeding  month  are  occupied  by  in- 
crease in  bulk  rather  than  by  great  gain  in  length.  The  skin  assumes  a 
brighter  flesh-color ;  the  scalp  is  plentifully  supplied  with  hair ;  the  nails 
almost  reach  the  finger-tips.  The  vernix  caseosa  forms  a  complete  coating ; 
the  lanugo,  or  embryonal  down,  begins  to  disappear.  The  subcutaneous  fat 
has  increased,  giving  less  harsh  outlines  to  the  body.  The  close  of  this  month 
finds  the  fetus  measuring  about  40  centimeters  (16  inches)  and  weighing  from 
2  to  2J-  kilograms  (4  to  5  pounds). 
.  The  Ninth  Month. — The  fetus  at  full  term  presents  usually  a  well-rounded 


PHYSIOLOGY  OF  PREGNANCY. 


103 


body,  from  which  the  lanugo  lias  almost  entirely  disappeared.  The  skin  is 
less  highly  colored,  and  is  covered  in  places,  particularly  the  head,  the  axilla, 
the  groin,  and  the  flexor  surfaces,  with  a  layer  of  protecting  veniix.  Both  tes- 
ticles have  descended  into  the  scrotum  ;  in  the  female  the  labia  majora  are  in 
contact.  The  intestinal  tract  contains  the  dark-greenish-colored  meconium, 
consisting  of  the  secretions  of  the  intestines  and  the  liver  mixed  with  the  epi- 


Fig.  91.— Diagram  illustrating  the  outlines  of  the  human  fetus  at  various  stages,  from  the  end  of  the 
second  to  the  end  of  'the  eighth  week,  magnified  five  times  (modified  after  Mall). 

thelium  from  the  digestive  tube,  together  with  epidermis  and  lanugo  swallowed 
by  the  fetus.  The  umbilicus  has  reached  a  position  almost  exactly  in  the 
middle  of  the  body.  The  first  epiphyseal  ossification  to  appear,  that  of  the 
lower  end  of  the  femur,  is  often  the  only  one  present,  but  ossification  may 
have  commenced  also  in  the  upper  epiphyses  of  the  tibia  and  the  humerus. 


104  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

A  convenient  simple  method  of  determining  the  approximate  length  of  the 
fetus  at  any  period  during  gestation  has  been  given  by  Haase.  The  length  in 
centimeters  may  roughly  be  estimated  up  to  the  end  of  the  fifth  month  by 
squaring  the  month  ;  beyond  the  end  of  the  fifth  month,  by  multiplying  the 
month  by  the  common  coefficient  5. 

Computed  by  this  method,  the  approximate  greatest  or  entire  lengths  of 
the  fetus  for  the  several  months  are : 


t  the  end  of    1  i 

nonth 

the 

length 

= 

1X1=    1  centimeter 

=    |  inch. 

"             "        2  months 

" 

" 

= 

2X2=    4  centimeters 

=    H  inches. 

3 

" 

" 

" 

= 

3X3=9 

=    3f      " 

"            "        4 

" 

" 

" 

= 

4  X  4  =  16           " 

=    6|       " 

"            "        5 

" 

" 

" 

= 

5  X  o  =  25           " 

=  10 

"            "        6 

" 

" 

" 

= 

6  X  5  =  30           " 

=  12         " 

7 

" 

" 

" 

= 

7X5  =  35 

=  14 

8 

" 

" 

" 

= 

S  X  5  =  40          " 

=  1(3 

9 

" 

" 

" 

= 

9  X  5  =  45           " 

=  18 

"            "      10 

" 

" 

" 

= 

10  X  5  =  50           " 

=  20 

The  full-term  fetus  measures,  on  an  average,  about  50  centimeters  (20 
inches)  in  its  entire  length,  and  weighs  from  3  to  3^-  kilograms  (from  6  to  7 
pounds),  the  average  weight  for  boys  being  3340  grams  (7  pounds,  6  ounces), 
and  that  for  girls  3190  grams  (7  pounds).  The  individual  variations  in  weight 
of  new-born  children  include  a  wide  latitude,  as  indicated  by  the  extremes 
of  717  grams  (1  pound,  94;  ounces)  and  6123  grains  (13  pounds,  8  ounces),  as 
accepted  by  Vierordt.  Children  really  exceeding  5  kilograms  (about  10  pounds 
at  birth  are  very  rare,  notwithstanding  numerous  reputed  cases.  Waller,  how- 
ever, reports  a  case  of  a  living  infant,  delivered  by  him  with  forceps,  that 
weighed  15  pounds  15  ounces  !  In  addition  to  sex,  boys  being  heavier  than 
girls,  the  size  of  the  child  is  materially  influenced  by  the  conditions  of  ma- 
ternal parentage;  thus:  (1)  Ypung  mothers  have  the  smallest  children,  and 
mothers  between  thirty  and  thirty-five  years  have  the  heaviest.  (2)  The  weight 
of  the  child  increases  with  the  number  of  previous  pregnancies,  providing  that 
the  successive  children  are  of  the  same  sex  and  that  the  pregnancies  do  not 
follow  too  rapidly ;  the  children  of  priiuiparse,  therefore,  average  less  than 
those  of  multiparas.  (3)  The  weight  of  the  child  increases  with  the  weight 
(Gassner)  and  the  length  (Frankenhausen)  of  the  mother.  In  addition,  ob- 
viously, all  causes  adversely  affecting  the  physical  condition  of  either  parent  may 
exert  an  unfavorable  influence  on  the  vitality  and  development  of  the  fetus. 

6.  Development  of  the  Circulatory  System. — The  vascular  system  is 
formed  by  the  development  of  two  parts,  at  first  entirely  distinct — the  extra- 
embryonic blood-vessels,  and  the  central  circulatory  apparatus  represented  by 
the  heart  and  the  great  primary  trunks.  The  extra-embryonic  blood-vessels 
constitute  successively  two  distinct  systems,  the  vitelline  and  the  allantoic  cir- 
culation. The  first  of  these  in  mammals  and  in  man  is  comparatively  unim- 
portant ;  the  second  is  of  the  utmost  importance,  since  it  takes  an  active  part 
in  securing  the  nourishment  of  the  embryo  from  the  maternal  tissues  by 
means  of  the  formation  of  the  placental  circulation  which  it  becomes. 


PHYSIOLOGY    OF  PREGNANCY. 


105 


Very  early  in  the  development  of  the  embryo  the  germinal  area  becomes 
mottled  by  the  appearance  at  its  periphery  of  an  irregular  network  of  branch- 
ing patches  of  darker  tint  than  the  surrounding  tissue,  due  to  the  active  cell- 
proliferation.  These  patches  are  the  blood-islands  of  Pander,  so  called  from 
the  active  role  played  by  them  in  the  production  of  vascular  tissue — vessels 
and  blood-cells.  By  the  extension  of  the  blood-islands  and  the  newly-formed 
vessels  the  circulation  within  the  area  vasculosa  (PI.  15)  rapidly  extends  cen- 
trally and  toward  the  embryo,  with  which  communication  is  later  established 
by  the  vitelline  arteries  and  veins,  large  trunks  which  connect  with  the  cephalic 
and  caudal  extremities  respectively  of  the  primitive  circulatory  apparatus 
which  has  meanwhile  been  developed  within  the  embryo.  The  significance 
of  the  vitelline  circulation  in  mammals  is  probably  merely  suggestive  of  its  far 
greater  importance  in  the  lower  types,  where  absorption  of  nutritive  materials 
from  the  large  and  conspicuous  yolk  constitutes  an  evident  reason  for  its 
development.  In  man  and  in  mammals  it  is  doubtful  whether  the  vitelline 
circulation  contributes  nutritive  substances  in  any  appreciable  degree. 

Coincidently  with  the  decrease  in  the  yolk-sac  and  its  vitelline  circulation, 
the  vessels  supplying  the  allantoic  tissues  become  more  prominent,  the  growth 
of  the  two  systems  proceeding  in  inverse  order.  The  conversion  of  a  portion 
of  the  vascular  chorion  into  the  fetal  contribution  of  the  placenta  advances 
the  importance  of  these  vessels  to  that  of  the  placental  circulation,  as  first 
represented  by  the  two  umbilical  veins  and  the  two  umbilical  arteries,  the 
latter  the  direct  continuations  of  the  intra-embryonic  hypogastric  arteries. 
Later,  the  two  veins  fuse  within  the  allantoic  stalk,  thereby  producing  a  single 
venous  trunk  which  accompanies  the  arterial  stems.  Within  the  body  of  the 
fetus,  however,  the  umbilical  veins,  which  there  remain  separate,  develop 
unequally,  the  right  suffering  atrophy  and  finally  disappearing,  while  the  left 
increases  in  size  and  persists  until  birth  as  the  important  umbilical  vein  con- 
veying the  blood  to  the  liver. 

The  Heart. — Coincidently  with  the  formation  of  the  primary  extra-embry- 
onic blood-vessels  within  the  vascular  area,  the  heart  early  begins  its  develop- 


FiG.  92. — Section  of  early  embryo  of  rabbit  (Piersol),  showing  two  separate  heart-tubes  (H,  H):  e, 
primitive  endothelium;  on,  mesoderm  forming  cardiac  wall ;  ec,  ectoderm;  en,  entoderm;  gf,  folds  pro- 
ducing ventral  wall  of  gut-tract ;  hg,  head-gut ;  a,  a',  primitive  aorta ;  n,  neural  canal. 

ment.     The  first  trace  of  this  important  organ  appears  as  a  folding  off  and 
hollowing  out  of  a  limited  mesodermic  area  on  each  side ;  the  two  heart-tubes 


106 


AMEBIC  AN   TEXT-BOOK    OF    OBSTETRICS. 


thus  formed  lie  within  the  splanchnic  mesoderm  and  are  at  first  widely  sepa- 
rated from  each  other  (Fig.  92).  With  the  bending  together  and  approxima- 
tion of  the  visceral  layers  in  the  formation  of  the  gut-tract  the  heart-tubes  are 
brought  into  apposition,  and  finally  fuse,  the  union  resulting  in  the  production 


Fig.  93.— Diagrams  illustrating  arrangement  of  primitive  heart  and  aortic  arches  (modified  from 
Allen  Thompson) :  1,  vitelline  veins  returning  blood  from  vascular  area ;  2,  venous  segment  of  heart- 
tube  ;  3,  primitive  ventricle  ;  4,  truncus  arteriosus ;  5,  5,  upper  and  lower  primitive  aorta? ;  5',  5',  continu- 
ation of  double  aortSB  as  vessels  to  caudal  pole  of  embryo  ;  6,  vitelline  arteries  returning  blood  to  vascu- 
lar area. 

of  a  short,  straight  receptacle,  into  the  caudal  end  of  which  empty  the  vitelline 
veins,  and  from  the  cephalic  extremity  pass  the  primitive  arterial  trunks 
(Fig.  93). 

This  early  straight  heart-tube,  l}Ting  attached  to  the  floor  of  the  pharyngeal 
region,  is  very  transient,  since  the  rapidly  increasing  length  of  the  organ,  its 


Fig.  94. — A,  heart  of  human  embryo  of  2.15  mm.  (His) :  a,  truncus  arteriosus ;  6,  primitive  ventricle ; 
c,  venous  segment.  B,  heart  of  human  embryo  of  about  3  mm.  (His):  a,  truncus  arteriosus;  b,  venous 
segment  (behind) ;  c,  primitive  ventricle  (in  front). 

ends  being  relatively  fixed,  soon  necessitates  flexion,  which  takes  place  in  both 
sagittal  and  transverse  planes,  and  results  in  giving  to  the  tube  the  S-form. 
The  lower  and  posterior  limb  of  the  heart  receives  the  great  veins  and  is  the 
sinus  venoms  (Fig.  94) ;  the  lower  and  anteriorly  directed  loop  is  the  auricular 


VI TKLLIXE   CIRCULATION. 


Vascular  area  of  eleven-day  rabbit  embryo  (E.  v.  Beneden  and  Julin) :  capillaries  not  shown :  the  terminal 
sinus  is  seen  to  be  arterial. 


PHYSIOLOGY   OF  PREGNANCY. 


lU? 


or  venous  compartment;  the  upper  and  posteriorly  directed  loop  is  the  ventric- 
ular or  arterial  compartment ;  the  upper  limb  is  the  truncus  arteriosus,  from 
which  arise  the  primitive  aortic  arches.  The  heart,  therefore,  at  this  stage — 
about  the  fourteenth  day — consists  essentially  of  two  imperfectly  separated 


Fig.  95. — A,  heart  of  human  embryo  of  about  4.3  mm.  (His) :  a,  atrium ;  6,  portion  of  atrium  corre- 
sponding with  auricular  appendage ;  c,  truncus  arteriosus ;  (/,  auricular  canal ;  e,  primitive  ventricle.  B, 
heart  of  human  embryo  of  about  the  fifth  week  (His) :  a,  left  auricle ;  6,  right  auricle ;  c,  truncus  arterio- 
sus ;  d,  interventricular  groove ;  e ,  right  ventricle  ;  /,  left  ventricle. 

divisions — a  lower  and  posterior  venous  chamber  and  an  upper  and  anterior 
arterial  compartment — into  and  from  which  pass  the  larger  primitive  venous 
and  arterial  trunks. 

The  venous  or  auricular  division  during  the  third  week  develops  two  con- 


Fig.  96.— A,  section  of  heart  of  human  embryo  of  10  mm.  (His) :  a,  septum  spurium ;  b,  interauricular 
septum ;  c,  mouth  of  sinus  reuniens ;  d,  right  auricle ;  e,  left  auricle  ;  /,  auricular  canal ;  g,  right  ven- 
tricle ;  ft,  interventricular  septum  ;  i,  left  ventricle.  B,  section  of  heart  of  human  embryo  of  about  the 
fifth  week  (His) :  a,  septum  spurium ;  b,  auricular  septum ;  c,  opening  of  sinus  reuniens  (leader  passes 
through  foramen  ovale) ;  d,  right  atrium ;  e,  left  atrium  ;  /,  septum  intermedium  ;  g,  right  ventricle ;  ft, 
ventricular  septum ;  i,  left  ventricle. 

spicuous  lateral  dilatations  which  assume  a  position  above  and  behind  the  grow- 
ing arterial  chamber.  These  dilatations  are  the  auricular  appendages  (Fig.  95), 
which  for  some  time  are  the  most  conspicuous  parts  of  the  auricles.     At  this 


108  AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 

time  the  auricular  and  ventricular  portions  of  the  heart  are  imperfectly  sepa- 
rated by  a  marked  constriction,  the  canalis  auricularis. 

During  the  fourth  week  the  conversion  of  the  single  into  a  double  heart 
commences  by  the  gradual  growth  of  partitions  from  above  downward  within 
the  auricle,  and  from  below  upward  within  the  ventricle  (Fig.  96,  a);  in  addi- 
tion, the  primitive  auriculo-ventricular  canal  becomes  divided  by  the  formation 
of  an  especial  partition,  the  septum  intermedium.  The  division  of  the  heart- 
chambers  progresses  to  complete  separation,  with  the  exception  of  an  orifice  in 
the  lower  part  of  the  interauricular  septum,  which  orifice  remains  until  shortly 
after  birth  as  the  foramen  ovale.  The  entrance  of  the  venous  blood  into  the 
auricular  compartment  is  effected  for  some  time  through  the  single  opening  of 
the  sinus  venosus.  Guarding  this  orifice  are  folds  of  the  cardiac  lining,  one  of 
which  folds  becomes  prominent  as  the  Eustachian  valve,  directing  the  blood- 
current  through  the  foramen  ovale.  Later,  the  sinus  venosus  becomes  included 
within  the  wall  of  the  heart,  and  the  three  principal  venous  trunks  emptying 
within  the  sinus — the  two  ducts  of  Cuvier  and  the  primitive  inferior  vena 
cava — open  directly  into  the  auricular  cavity  by  as  many  separate  orifices ; 
that  of  the  left  Cuvierian  duct  is  represented  by  the  mouth  of  the  coronary 
sinus,  which  this  trunk  eventually  becomes.  The  truncus  arteriosus,  the  ante- 
rior primary  arterial  trunk,  undergoes  an  independent  division  by  the  forma- 
tion of  the  aortic  septum,  the  partition  beginning  at  some  distance  from  the 
heart  and  approaching  the  latter  from  above  downward.  The  vessels  resulting 
from  the  division  of  the  single  truncus  arteriosus  afterward  become  the  aorta 
and  the  pulmonary  artery,  and  are  limited  respectively  to  the  left  and  right 
halves  of  the  ventricular  compartment  by  the  simultaneously  developed  inter- 
ventricular septum. 

The  primitive  heart,  as  well  as  the  earliest  blood-vessels,  consists  of  a 
double  wall,  the  outer  layer  representing  the  muscular  and  fibrous  tissue,  and 
the  inner  layer  representing  the  endothelial  lining.  These  two  coats  are  for  a 
time  entirely  distinct,  the  endothelial  heart  representing  the  general  arrange- 
ment and  division  of  the  organ,  and  lying  within  the  surrounding  layer  as  a 
shrunken  cast  within  a  mould  (see  Fig.  106).  The  interval  separating  the  endo- 
thelial from  the  muscular  heart  later  becomes  bridged  by  numerous  connecting 
bands  of  tissue,  the  network  of  trabecular  becoming  closer  and  the  intervening 
spaces  smaller  as  development  progresses.  The  consolidation  of  the  cardiac 
walls,  however,  never  is  completely  accomplished,  indications  of  its  imperfec- 
tions being  clearly  seen  in  the  arrangement  of  the  conspicuous  columnar  carnece 
of  the  adult  organ,  in  which  the  more  or  less  isolated  bands  represent  the 
thickened  remains  of  the  bridging  trabecular  connecting  the  endothelial  heart 
with  the  denser  surrounding  capsule. 

Arteries  of  the  Fetus. — The  early  arterial  circulation  of  the  fetus  dif- 
fers in  many  details  from  that  of  the  later  stages.  Conspicuous  among  these 
differences  is  the  development  of  the  series  of  aortic  arches  which  extend  from 
the  anterior  end  of  the  truncus  arteriosus  around  the  primitive  pharynx, 
within  the  visceral  arches,  and  converge  into  the  dorsal  longitudinal  vessels, 


PHYSIOLOGY   OF  PREGNANCY.  109 

the  primitive  aortce,  on  each  side.     Five  pairs  of  aortic  arches  (Figs.  93,  97)  are 


Fig.  97.— Human  embryo  of  about  three  weeks,  showing  visceral  arches  and  furrows  and  then-  rela- 
tions to  aortic  arches  (His) :  mx,  mn,  maxillary  and  mandibular  processes  of  first  visceral  arch ;  a  1-alV. 
first  to  fourth  aortic  arches  ;  jv,  cv,  primitive  jugular  and  cardinal  veins ;  dC,  duet  of  Cuvier ;  at,  v,  atrium 
and  ventricle  of  primitive  heart ;  vs,  vitelline  sac ;  va,  da,  ventral  and  dorsal  aortee ;  ov,  ot,  optic  and  otic 
vesicles  ;  uv,  ua,  umbilical  veins  and  arteries ;  iro,  vitelline  vein ;  al,  allantois. 

formed,  the  first  pair  lying  within  the  corresponding  mandibular  arch,  the  last 


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AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 


within  the  tissues  of  the  imperfectly  defined  fifth  visceral  bow.  The  first  pair 
earliest  appears  and  soonest  disappears,  all  five  at  no  time  being  found  simul- 
taneously fully  developed,  since  by  the  twentieth  day,  when  all  are  present,  the 
anterior  arches  have  already  partly  atrophied.  These  aortic  arches  in  man  and 
in  mammals  transiently  represent  the  branchial  circulation  of  gill-bearing 
types ;  their  identity  in  the  higher  animals  is  lost  in  the  metamorphosis  which 
they  undergo  in  the  development  of  permanent  trunks. 

The  fate  of  the  several  aortic  arches  and  their  relations  to  persistent  struc- 
tures is  briefly  as  follows  (Fig.  98) : 

(1)  The  first  or  mandibular  aortic  arch  early  in  the  fourth  week  loses  its 
middle  segment,  the  anterior  limb  taking  part  in  the  formation  of  the  external 


Common  carotid. 

Recurrent  hit  v>:£Cal  }wrve. 


Right  subclavian 


Fig.  98. — Diagram  illustrating  the  fate  of  the  aortic  arches  in  mammals  and  man  'modified  from  Rathke). 

carotid  artery  and  its  branches ;  the  posterior  or  aortic  limb  aids  in  forming 
the  internal  carotid  artery. 

(2)  The  second  arch  has  a  fate  identical  with  that  of  the  first,  its  straighter 
ventral  and  dorsal  limbs  taking  part  in  producing  the  carotids. 

(3)  The  third  arch,  which  remains  almost  complete,  gives  rise  to  the  connec- 
tion between  the  external  and  internal  carotid  arteries,  to  the  latter  of  which 
the  arch  particularly  contributes. 

(4)  The  fourth  arch  undergoes  important  changes  resulting  in  its  retention 
on  the  two  sides,  since  from  it  are  largely  derived  the  innominate,  together 
with  the  subclavian  and  vertebral  arteries  on  the  right  side,  and  the  important 
arch  of  the  aorta  on  the  left. 


PHYSIOLOGY  OF   PREGNANCY.  Ill 

(5)  The  fifth  arch  is  devoted  to  the  production  of  the  pulmonary  arteries,  a 
small  portion  of  the  right  arch  persisting  as  the  right  pulmonary  artery,  and 
a  larger  part  of  the  left  giving  origin  to  the  corresponding  pulmouary  artery 
and  the  ductus  arteriosus. 

During  the  fifth  week,  as  before  noted,  the  truncus  arteriosus  undergoes  divis- 
ion into  two  tubes  by  the  formation  of  the  aortic  septum  ;  the  resulting  aortic 
tube  retains  connection  with  the  fourth  arch,  becoming  the  ascending  portion 
of  the  arch  of  the  aorta,  while  the  right  tube  becomes  connected  with  the  fifth 
arch  and  forms  the  pulmonary  vessel. 

The  two  primitive  aortse  for  a  time  extend  on  each  side  of  the  notochord 
as  longitudinal  vessels  which  almost  completely  terminate  in  the  large  omphalo- 
mesenteric or  vitelline  arteries  supplying  the  circulation  of  the  yolk-sac,  the 
early  continuation  of  the  aortic  stems  being  slender,  relatively  insignificant 
branches  which  extend  toward  the  caudal  pole  of  the  embryo.  With  the 
development  of  the  earliest  allantoic  structures  the  posterior  segments  of  the 
two  primitive  aortse  unite  to  form  a  single  trunk,  the  dorsal  aorta,  the  fusion 
beginning  about  the  junction  of  the  cervical  and  thoracic  regions  and  pro- 
ceeding caudally.  At  a  slightly  later  period  the  aortic  trunk  divides,  at  the 
end  of  the  lumbar  region,  into  the  allantoic  arteries,  which  pass  along  the 
allantoic  stalk  and  are  distributed  to  the  chorion,  and  later  to  the  fetal  placenta  ; 
they  are  then  known  as  the  umbilical  arteries  as  far  as  the  body-wall,  being 
continued  within  the  embryo  as  the  hypogastrics.  The  primitive  allantoic 
arteries  eventually  become  the  common  and  the  internal  iliac  arteries,  the 
external  iliacs  being  formed  as  new  branches  when  the  limbs  are  developed. 
After  birth,  when  the  fetal  placental  circulation  ceases,  the  distal  parts  of  the 
hypogastrics  beyond  the  bladder  atrophy  and  remain  as  solid  fibrous  cords 
passing  to  the  umbilicus ;  the  proximal  parts  of  these  vessels  retain  their 
lumina  and  persist  as  the  superior  vesical  arteries. 

Veins  of  the  Fetus. — Toward  the  close  of  the  embryonal  period,  about 
the  fourth  week,  the  venous  arrangement  includes  three  distinct  sets  of  vessels 
returning  the  blood  to  the  heai*t  (PI.  16) ;  these  are — (1)  The  Cuvierian  veins, 
returning  the  blood  from  the  body  of  the  embryo  ;  (2)  the  vitelline  veins,  re- 
turning the  blood  from  the  circulation  of  the  yolk-sac ;  (3)  the  allantoic,  later 
the  umbilical,  veins,  returning  the  blood  from  the  chorion  and  the  developing 
placental  structures.  The  early  systemic  veins  consist  of  an  upper  trunk,  the 
anterior  cardinal  or  primitive  jugular  veins,  by  which  the  blood  from  the  head 
is  carried  to  the  heart,  and  the  jiosterior  cardinals,  collecting  the  blood  from 
the  trunk  and  the  important  Wolffian  bodies.  These  vessels,  along  with  the 
vitelline  and  allantoic  veins,  pour  their  blood  into  a  common  receptacle,  the 
sinus  venosus,  which  opens  directly  into  the  primary  auricular  division  of  the 
heart.  For  a  short  time  these  veins  are  about  equal  in  size  and  are  evenly 
developed  on  the  two  sides  ;  soon,  however,  the  results  of  unequal  growth  become 
manifested  in  the  disproportionate  advance  of  some  and  the  retrogression  of 
others. 

The  vitelline  veins  in  man,  as  may  be  anticipated  from  the  relative  insig- 


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AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


nificance  of  the  mammalian  yolk-sac,  never  reach  the  development  seen  in 
lower  types.  After  passing  along  the  vitelline  stalk  and  entering  at  the  umbil- 
ical opening,  the  veins  run  in  front  and  then  at  the  sides  of  that  part  of  the 
primitive  gut-tract  corresponding  with  the  duodenum,  and  become  closely  asso- 
ciated with  the  liver  (Fig.  99).  The  vitelline  veins  become  connected  by  three 
newly  formed  transverse  trunks,  thus  establishing  two  vascular  rings  which 
encircle  the  gut.     The  early  direct  communication  above  these  rings  with  the 

VE    PA  VA" 


vv     ri   rv 


Pig.  99.— Development  of  the  portal  circulation  of  the  human  embryo  of  about  three  and  a  half  weeks 
(Marshall,  after  His) :  PA,  pancreas;  TI,  intestines ;  TS,  stomach;  WD,  bile-duct ;  VA,  left  allantoic  vein  ; 
VA',  right  allantoic  vein ;  VA",  anterior  detached  portions  of  the  allantoic  veins  ;  VE,  ductus  venosus ; 
VO,  portal  vein ;   VV,  vitelline  vein ;   VV,  portions  of  sinus  annulares  which  disappear ;   W,  liver. 

sinus  venosus  becomes  lost,  and,  at  the  same  time  portions  of  the  remaining 
parts  of  the  vitelline  veins  become  interrupted,  while  a  new  capillary  system 
appears  within  the  hepatic  tissue,  which  has  meanwhile  surrounded  the  vessels, 
and  provides  communication  between  the  veins  themselves.  Those  portions 
of  the  vitelline  vessels  that  pass  from  the  upper  venous  ring  to  the  capillary 
network  are  known  as  the  venae  advehentes :  they  become  the  branches  of  the 
portal  vein  ;  those  portions  which  pass  from  the  capillary  network  to  the  sinus 
venosus,  forming  new  relations,  are  the  vence  revehentes  and  they  become  the 
hepatic  veins.  The  vitelline  veins  at  their  lower  communication  become  com- 
pletely fused  and  receive  veins  from  the  intestinal  tract,  thus  forming  the  main 
portal  trunk. 

The  allantoic  veins  after  the  establishment  of  the  placental  circulation  are 
known  as  the  umbilical  veins,  of  which  for  a  time  there  are  two.  They  fuse 
within  the  allantoic  stalk,  but  remain  as  distinct  vessels  within  the  embryo, 
running  within  the  lateral  walls,  for  a  much  longer  period.  During  the 
fourth  week  the  connection  of  the  allantoic  veins  with  the  sinus  venosus  is 
lost,  and  shortly  afterward  the  right  vein  becomes  much  smaller  than  its 
fellow,  and   filially  undergoes    atrophy.     The   much   larger  left  allantoic  or 


PHYSIOLOGY   OF  PREGNANCY.  113 

umbilical  vein  joins  the  primitive  portal  vein  just  as  this  vessel  enters  the 
hepatic  tissue. 

The  early  condition  of  the  placental  circulation  for  a  time  is  such  that 
all  blood  returning  by  the  allantoic  vein  must  traverse  the  capillary  network 
of  the  liver  in  order  to  gain  access  to  the  heart,  since  both  vitelline  and 
allantoic  veins  have  lost  their  direct  communication  with  the  sinus  venosus. 
After  a  time,  however,  the  liver  is  no  longer  capable  of  giving  passage  to  the 
rapidly  increasing  volume  of  the  placental  circulation,  and  then  a  direct  com- 
munication is  established  between  the  portal  vein  and  the  right  hepatic  vein. 
This  new  passage  is  the  ductus  venosus,  by  which  the  greater  part  of  the  blood 
is  carried  to  the  heart  without  traversing  the  hepatic  substance. 

The  systemic  veins  arise  partly  from  the  primary  venous  trunks  and 
partly  as  new  vessels.  The  ducts  of  Cuvier  receive  the  primitive  jugular 
veins  above  and  the  cardinal  veins  below.  The  primitive  jugulars  later 
become  the  permanent  external  jugulars,  the  internal  jugulars  being  formed  as 
new  trunks.  The  Cuvierian  ducts,  which  undergo  change  of  direction  and 
lengthening,  take  a  position  almost  vertical,  becoming  the  superior  vence  cavce, 
of  which  there  are  at  first  two.  The  development  of  the  heart  induces  the 
disappearance  of  the  greater  part  of  the  left  superior  cava,  the  proximal  end, 
however,  remaining  as  the  insignificant  coronary  sinus  which  directly  opens 
into  the  right  auricle.  With  the  atrophy  of  the  left  caval  trunk  a  new 
transverse  communication  is  necessitated  to  convey  the  blood  from  the  left 
side  to  the  remaining  and  enlarging  superior  cavse.  This  need  is  supplied  by 
the  formation  of  the  transverse  jugular,  which  later  becomes  the  greater  part 
of  the  left  innominate  vein. 

The  fate  of  the  once  important  posterior  cardinal  veins  is  linked  with  the 
history  of  the  AVolffian  bodies,  whose  venous  outlet  these  veins  largely  are. 
With  the  atrophy  of  the  Wolffian  bodies  the  cardinal  veins  become  less 
important,  their  final  fate  being  partial  disappearance  and  partial  persistence 
as  the  azygos  veins  of  adult  anatomy. 

The  inferior  vena-  cava  presents  a  complicated  development,  for  the  details 
of  which  we  are  largely  indebted  to  the  recent  investigations  of  Hochstetter. 
The  inferior  cava  is  developed  partly  as  an  independant  trunk,  and  partly 
depends  upon  the  appropriation  of  already  existing  veins.  A  new  vessel  is 
formed  from  the  proximal  end  of  the  ductus  venosus,  from  the  point  where 
that  canal  joins  the  hepatic  veins,  downward  as  far  as  the  superior  mesenteric 
artery,  when  it  divides  into  two  branches  which  join  the  primitive  cardinals. 
This  new  vessel  contributes  the  hepatic  portion  of  the  inferior  vena  cava. 
The  further  course  of  the  latter  vessel,  as  well  as  of  the  right  common  iliac 
vein,  is  provided  for  by  the  enlargement  and  extension  of  the  lower  part  of 
the  right  primitive  cardinal  vein,  that  of  the  opposite  disappearing.  The 
external  iliacs  and  the  greater  part  of  the  left  common  iliac  vein  are  new 
vessels. 

7.  Development  of  the  Digestive  Tract.— The  formation  of  the  digestive 
tube  consists  essentially  in  the  folding  off,  closure,  and  isolation  of  that  part 


114 


AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 


of  the  yolk-sac  immediately  in  contact  with  the  axial  portions  of  the  ento- 
derm. This  differentiation  is  effected  by  the  ventral  extension  and  approxi- 
mation of  the  widely  expanded  splanchnopleure,  which,  bending  together 
(Fig.  100),  gradually  closes  to  form  the  primitive  gut — at  first  freely  opening 
into  the  yolk-sac,  finally  completely  isolated  from  the  latter  except  through 
the  communication  maintained  by  the  narrow  umbilical  duct. 

By  the  fifteenth  day  the  gut  has  become  defined  to  such  extent  that  three 
parts  are  distinguishable — the  fore-gut,  the  mid-gut,  and  the  hind-gut.  The 
fore-gut,  which  includes  the  cephalic  third  of  the  tube,  gives  rise  to  the  phar- 
ynx, the  esophagus,  and  the  stomach,  the  latter  organ  early  appearing  as  a 
fusiform  enlargement  of  the  primitive  canal.  The  anterior  end  of  the  fore- 
gut  reaches  as  far  forward  as  the  marked  cephalic  flexure  opposite  the  mid- 
brain, and  at  first  is  separated  from  the  primitive  oral  invagination,  or  sto- 


Fig.  100.— Transverse  section  of  a  sixteen  and  a  half  day  sheep  embryo  (Bonnet). 

matodceum  (Fig.  101,  a,  b),  by  a  septum  consisting  of  the  opposed  ectodermic 
and  entodermic  layers.  After  the  rupture  of  this  partition,  which  happens 
during  the  fifteenth  day,  the  primitive  pharynx  and  oral  cavity  are  directly 
continuous. 

A  series  of  four  diverticula  extend  between  the  visceral  arches,  and  constitute 
the  pharyngeal  pouches  ox  inner  visceral  furrows  (Fig.  106;  PI.  16).  These 
evaginations  of  the  pharyngeal  lining  are  of  interest,  since  the  first  pouch 
gives  rise  to  the  Eustachian  tube  and  the  tympanic  cavity,  the  third  pouch 
to  the  early  epithelial  thymus  body,  and  the  fourth  pouch  to  the  lateral  por- 
tions of  the  early  thyroid  body.  From  the  ventral  surface  of  the  fore-gut, 
at  the  end  of  its  pharyngeal  division,  there  grows  out  the  diverticulum, 
which  gives  rise  to  the  respiratory  tube  and  the  epithelial  parts  of  the  pul- 
monary tissues. 


PHYSIOLOGY   OF  PREGNANCY. 


115 


The  mid-gut,  at  first  in  free  communication  with  the  yolk-sac  through  the 
wide  yolk-stalk,  gradually  becomes  tubular  and  elongated,  forming  a  narrow 
V-shaped  loop  whose  straight  and  almost  parallel  limbs  are  attached  behind  to 
the  dorsal  wall  of  the  body-cavity,  above  to  the  terminal  part  of  the  fore-gut 
at  the  stomach,  and  below  to  the  hind-gut  (Fig.  102).  The  apex  of  the  loop 
receives  the  reduced  yolk-stalk  or  umbilical  duct,  thereby  becoming  attached 
A  B 


Fig.  101.— Reconstructions  of  human  embryo  of  about  fifteen  days  (His) :  acv,  men,  pcv,  anterior,  mid- 
dle, and  posterior  primary  brain- vesicles  ;  ov,  ot,  optic  and  otic  vesicles ;  s(,  septum  between  primitive 
oral  cavity  and  head-gut;  pg,  primitive  gut;  v,  la,  ventricular  and  aortic  segments  of  heart;  a',  aortic 
arch ;  va,  da,  ventral  and  dorsal  aortse ;  I,  liver ;  hg,  hind-gut ;  nc,  notochord  ;  s,  somites ;  sr,  sinus  reuniens  ; 
vv,  vitelline  veins ;  uv,  ua,  umbilical  veins  and  arteries ;  al,  allantois. 


to  the  ventral  body-wall.  The  mid-gut  gives  rise  to  the  entire  small  intestine 
and  to  the  greater  part  of  the  large  intestine.  The  liver  and  the  pancreas  are 
formed  as  diverticula  and  outgrowths  from  the  lumen  and  the  epithelial  lining 
of  the  duodenal  portion  of  the  mid-gut. 

The   hind-gut    soon    loses    its    individuality   and    contributes    the    lower 
segment  of   the   large    intestine.     In    its    primitive    condition    the    hind-gut 


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AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 


includes  that  portion  of  the  gut-tract  lying  behind  the  open  mid-gut  and  ter- 
minating blindly  in  the  sharply  flexed  caudal  pole  of  the  embryo  ;  the  greatly 


k-±z. 


Fig.  102.— Intestinal  canal  of  human  embryo  of 
six  weeks  (Toldt). 


Vitelline  duct. 


Fig.  103. — Digestive  tract  of  human  embryo  of 
the  sixth  week  (Toldt) :  arrangement  of  primitive 
visceral  peritoneum. 


dilated  closed  end  of  the  tube  constitutes  the  cloaca,  the  common  receptacle 
for  a  time  of  the  excretions  of  both  the  alimentary  and  the  urinary  tracts. 

A  Lung.     Stomach.  B 


I  'iteiUne  duct 


Fig.  104.— A,  alimentary  tract  of  human  embryo  of  thirty-two  days.    B,  alimentary  tract  of  human 
embryo  of  thirty-five  days  (His). 

The  lumen  of  the  allantoic  sac,  surrounded  by  the  tissue  of  the  allantoic  stalk, 
extends  from  the  ventral  aspect  of  this  space.  At  a  later  period  communi- 
cation with  the  exterior  is  established  by  the  formation  of  the  anal  orifice. 
The  external  position  of  this  opening  is  indicated  by  the  anal  invagination  of 
the  ectoderm  or  proctodeum. 


PHYSIOLOGY    OF  PREGNANCY. 


117 


During  the  early  part  of  the  fourth  week  the  intestinal  tube,  composed  of 
its  several  characteristic  segments,  lies  in  the  sagittal  plane  attached  to  the 
dorsal  wall  of  the  body-cavity  by  the  straight  primitive  mesentery  (Fig.  103). 
A  few  days  later  a  period  of  rapid  growth  is  inaugurated,  the  intestinal  tube 
increasing  in  length  with  far  greater  rapidity  than  the  abdominal  cavity 
expands.  In  consequence  of  this  inequality  in  growth  the  small  intestines 
become  twisted  and  coiled,  while  the  large  gut  takes  up  a  position  in  front 
or  ventrally,  and  above  the  turns  of  the  smaller  tube. 

During  the  fifth  week  (Fig.  104)  the  esophagus  elongates  and  the  stomach 
acquires  its  characteristic  form  as  well  as  an  obliquely  transverse  position,  its 


Fig.  105— A,  outline  of  alimentary  canal  of  human  embryo  of  twenty-eight  days  (His) :  pb,  pituitary 
fossa ;  tg,  tongue ;  Ix,  primitive  larynx  ;  o,  esophagus  ;  tr,  trachea ;  Ig,  lung ;  s,  stomach ;  p,  pancreas ;  hd, 
hepatic  duct ;  vd,  vitelline  duct ;  al,  allantois ;  hg,  hind-gut ;  Wd,  Wolffian  duct ;  k,  kidney.  B,  outline 
of  alimentary  canal  of  human  embryo  of  thirty-five  days  (His) :  pb,  pituitary  fossa;  tg,  tongue  ;  Ix,  primi- 
tive larynx ;  o,  esophagus ;  tr,  trachea  ;  Ig,  lung ;  s.  stomach ;  p,  pancreas ;  hd,  hepatic  duct ;  c,  cecum ; 
cl,  cloaca ;  k,  kidney  ;  a,  anus ;  gp,  genital  eminence  ;  t,  caudal  process. 

former  left  side  becoming  directed  anteriorly  and  upward,  its  former  right  side 
looking  backward  and  downward.  The  cecum  for  a  time  is  situated  high  up 
and  in  close  relation  with  the  transversely  placed  portion  of  the  large  intestine  ; 
later  the  blind  end  of  this  part  of  the  gut  descends,  owing  to  the  development 
of  an  intermediate  portion  which  assumes  the  position  and  characteristics  of  the 
ascending  colon.  The  cecum  for  a  time  is  of  uniform  size  ;  its  further  growth, 
however,  is  marked  by  the  failure  of  the  apical  portion  to  keep  pace  with  the 
increase  in  size  of  the  remaining  parts  of  the  gut ;  in  consequence,  that  poi'tion 
which  morphologically  represents  the  end  of  the  cecum  remains  as  a  narrow 
tubular  attachment  connected  with  the  head  of  the  large  gut,  this  appendage 
constituting  the  appendix  vermiformis — the  oldest  part  of  the  cecum. 


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The  connection  of  the  yolk-stalk  or  vitelline  duct  (Fig.  105)  with  the  intes- 
tinal caDal  rapidly  becomes  less  conspicuous,  and  by  the  end  of  the  fifth  week 
the  yolk-stalk  has  but  slight  connection  with  the  gut.     The  position  of  the 


Fig.  106.— Reconstructions  of  human  embryo  of  about  seventeen  days  (His):  ov,  optic  and  ot,  otic 
resides;  nc,  nc',  notochord ;  hdg,  head-gut;  g,  mid-gut;  hg,  hind-gut;  vs,  vitelline  sac;  I,  liver;  v,  ta, 
primitive  ventricle  and  truncus  arteriosus;  va,  da,  ventral  and  dorsal  aortse;  aa,  aortic  arches;  jv,  primi- 
tive jugular  vein  ;  cc,  cardinal  vein;  dC,  duct  of  Cuvier;  uv,  ua,  umbilical  vein  and  artery;  al,  allantois; 
uc,  umbilical  cord. 

juncture  of  the  vitelline  duct  with  the  intestinal  tract  varies  greatly,  but  usually 
corresponds  with  a  point  within  the  small  intestine  from  40  to  60  centimeters 
(16  to  24  inches)  from  the  ilio-cecal  valve.  When  the  usually  atrophic  cord  is 
replaced  by  a  tubular  recess,  the  persistent  portion  of  the  duct  constitutes 
Meckel's  diverticulum,  a  structure  of  interest.  The  vitelline  duct  may  remain 
pervious  throughout  its  intra-embryonal  extent,  resulting  sometimes  in  congen- 
ital umbilical  fistula.    The  ventrally  situated  intestinal  loops  for  a  time  extend 


PHYSIOLOGY   OF  PREGNANCY.  119 

through  the  umbilical  opening  into  the  allantoic  stalk,  in  which,  up  to  the 
twelfth  week,  they  are  normally  present ;  after  the  third  month,  however,  the 
coils  are  permanently  withdrawn  into  the  abdominal  cavity. 

The  liver  first  appears  about  the  fifteenth  day  as  a  diverticulum  (Fig.  106) 
from  the  ventral  wall  of  the  fore-gut,  surrounded  at  its  end  by  a  thick  layer 
of  cells.  The  organ  is  rapidly  formed,  the  single  diverticulum  almost  imme- 
diately dividing  into  two,  which  in  turn  send  off  secondary  and  tertiarv  sprout- 
like extensions  of  solid  cell-masses.  These  cylindrical  masses  anastomose  and 
form  networks  of  cells  throughout  the  mesodermic  tissue  assigned  to  the  pro- 
duction of  the  liver.  The  spaces  within  the  rueshworks  are  occupied  by  the 
richly  vascular  mesodermic  tissue  which  supplies  the  connective  tissue  and  the 
contained  blood-vessels  and  bile-ducts. 

The  pancreas  (Fig.  105)  and  the  salivary  glands  are  developed  as  solid 
outgrowths  from  the  epithelium  of  the  digestive  tract.  The  cylindrical  cell- 
masses  at  first  are  slender,  solid,  and  rather  club-shaped  at  their  free  ends. 
The}7  later  acquire  a  lumen  and  expand  into  the  characteristic  compartments 
of  a  racemose  gland. 

8.  Respiratory  Tract. — The  respiratory  tract  is  closely  related  in  its  devel- 
opment with  the  digestive  canal,  since  it  is  formed  by  a  direct  evagination  from 
the  ventral  wall  of  the  lower  portion  of  the  primitive  pharynx.  The  primitive 
trachea  grows  downward  for  some  distance  parallel  with  the  esophagus,  and  then 
divides  into  branches  which  correspond  to  the  primary  and  secondary  bronchi 
(Figs.  104,  105) ;  subsequently  each  of  these  undergoes  repeated  dichotomous 

-division,  the  resulting  twigs  in  turn  giving  rise  to  smaller  branches  until  the 
ultimate  compartments  of  the  pulmonary  tissue  are  developed.  The  smaller 
primary  bronchioles  are  solid  cylinders  at  first,  their  lumina  appearing  later. 
The  entodermic  portion  of  the  respiratory  tract,  directly  derived  from  that  of 
the  primary  digestive  tube,  forms  the  epithelial  parts  of  the  organs,  the  con- 
nective tissues  and  vascular  constituents  of  the  same  being  products  of  the 
mesodermic  tracts  into  which  extend  the  epithelial  masses. 

9.  Development  of  the  G-enito-urinary  Organs. — The  early  stages  of 
the  human  embryo,  as  well  as  of  other  mammals,  mark  the  appearance  of 
the  paired  Wolffian  bodies  and  the  Wolffian  ducts,  which  for  a  time  repre- 
sent a  functionating  excretory  apparatus  (PI.  16),  the  ancestor  of  the  per- 
manent kidneys. 

The  Wolffian  duct  appears  about  the  fifteenth  day  as  a  longitudinal  cell- 
mass  extending  throughout  the  posterior  half  of  the  embryo.  The  duct  is 
formed  by  the  evagination  and  isolation  of  portions  of  the  mesothelial  lining 
of  the  body-cavity,  the  resulting  cylindrical  cell-mass  forming  a  cord  that 
extends  at  first  to  the  surface  ectoderm,  with  which  it  has  temporarily  close 
relations  (Fig.  107).  These  appearances  have  given  rise  to  the  views  advanced 
by  several  investigators,  according  to  which  the  Wolffian  duct  is  ectodermic  in 
origin.  Careful  examinations  of  suitable  preparations  show  that  the  relations 
of  the  developing  Wolffian  duct  to  the  ectoderm  are  only  secondary,  and  that 
the  initial  steps  in  the  formation  of  the  duct  occur,  as  stated,  as  evaginations  of 


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AMERICAN    TEXT-BOOK    OF    OBSTETBICS. 


the  niesothelium  ;  the  Wolffian  duct  therefore  is  a  product  of  the  mesoderm. 
After  a  time  the  blindly  terminating  distal  ends  of  the  ducts  sink  centrally 
and  acquire  a  communication  with  the  cloacal  expansion  of  the  hind-gut. 
At  first  the  ducts  are  solid  cylinders  ;  subsequently  they  possess  a  lumen. 


Fig.  107. — Transverse  section  of  sixteen  day  sheep  embryo  (Bonnet):  ec,  ectoderm;  en,  entoderm s 
pm,  parietal  mesoderm ;  vm,  visceral  mesoderm ;  am,  amnion  ;  ams,  amniotic  sac  ;  s,  s',  somites ;  a,  a', 
aortse ;  nc,  notoehord ;  n,  neural  canal ;   Wd,  Wolffian  duct ;   Wb,  Wolffian  body. 

Some  days  later,  usually  about  the  eighteenth  day,  the  Wolffian  bodies 
appear  as  a  series  of  short  cylinders  (Fig.  108)  which  form  as  buds  from  the 
mesothelium  of  the  body-cavity  entirely  independently  of  the  development  of 
the  Wolffian  duct.  These  rods  of  cells  at  first  are  solid  ;  during  the  fourth 
week  they  acquire  lumina  and  become  the  Wolffian  tubules,  and  later  grow 
toward  and  join   with  the  Wolffian  ducts.     The  closed  ends  of  the  tubules 


Fig.  108. — Transverse  section  of  seventeen  day  sheep  embryo  (Bonnet) :  am,  amnion;  as.  amniotic  sac; 
n,  neural  canal ;  s,  somite  differentiated  into  muscle-plate:  Wd,  Wolffian  duct;  Wb,  Wolffian  body;  pm, 
parietal  mesoderm ;  I'm,  visceral  mesoderm  ;  a,  a,  fusing  primitive  aorta? ;  i,  intestine. 

become  expanded  and  then  invaginated  by  the  apposition  of  blood-vessels  sent 
into  the  bodies  from  the  aorta.  The  tufted  blood-vessels  and  the  invaginated 
tubule  constitute  the  Malpighian  bodies  of  the  Wolffian  bodies,  the  predeces- 
sors of  the  similar  structures  of  the  permanent  kidney.  All  parts  of  the 
Wolffian  bodies,  therefore,  are  derived  from  the  mesodermic  tissues.  Second- 
ary tubules  are  formed  as  outgrowths  from  the  primary  ones  whose  origin  has 
been  sketched  above. 


PHYSIOLOGY   OF  PREGNANCY. 


121 


The  Wolffian  bodies  increase  rapidly  during  the  second  month,  gaining  in 
size  by  the  growth  of  the  primary  tubules  and  by  the  formation  of  new  ones. 
These  bodies  act  for  a  time  as  functionating  excretory  organs,  the  period  of 
their  greatest  development  being  about  the  eighth  week.  After  this  time  they 
undergo  retrogressive  change,  so  that  by  the  fifth  month  the  Malpighian  bodies 
liave  largely  disappeared  and  the  entire  organs  become  atrophic. 

In  view  of  important  differences  in  growth,  functional  activity,  and  mor- 
phological significance  of  various  parts  of  the  Wolffian  body,  there  are  recog- 


Fig.  109.— Reconstructed  human  embryo  of  about  twenty-eight  days  (His):  I-IV,  brain-vesicles- 
nc,  neural  canal ;  nch,  notochord;  ol,  olfactory  pit;  v,  au,  cardiac  ventricle  and  auricle;  va,da,  ventral 
and  dorsal  aortse ;  da',  termination  of  dorsal  aorta ;  tb,  median  part  of  thyroid  body ;  tr,  larynx  ;  Ig,  lung ; 
s,  stomach ;  p,  pancreas ;  i,  intestine ;  i' ,  intesto-vitelline  duct ;  al,  allantoic  duct ;  k,  kidney ;  ves,  left 
superior  vena  cava  ;  cv,  cardinal  vein ;  pv,  portal  vein ;  vas,  vena  ascendens,  collecting  blood  from  umbil- 
ical and  portal  veins  ;  uv,  umbilical  vein. 

nized  an  anterior  segment,  corresponding  with  the  head-kidney  of  lower  types, 
always  backward  in  its  development  in  mammals ;  a  middle  segment,  which 
from  its  relation  to  the  generative  organs  in  their  formation  may  be  regarded 
as  the  sexual  portion  of  the  organ ;  and  a  posterior  segment,  likewise  rudi- 
mentary in  development  and  in  the  nature  of  the  organs  to  which  it  contributes. 
The  middle  segment  is  of  most  importance  both  functionally  and  morpho- 
logically :  this  portion  is  sometimes  designated  the  mesonephros. 

The  Mullerian  Duct. — Coincidently  with  the  formation  of  the  Wolffian 


122  AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 

duct,  during  the  fourth  week,  an  extended  ridge  of  thickened  inesotheliuin 
appears  along  the  outer  side  of  each  Wolffian  body,  from  which,  however,  this 
ridge  is  entirely  independent.  These  ridges  represent  the  early  condition  of 
the  Mullerian  ducts,  the  lumina  appearing  within  the  cell-cords  about  the  fifth 
week.  The  Mullerian  duct  ends  blindly  below,  and  later  possesses  an  ex- 
panded, trumpet-shaped  anterior  end.  Its  important  morphological  relations 
are  considered  in  subsequent  paragraphs. 

The  permanent  excretory  organ,  the  kidney,  and  its  duct,  the  ureter,  are 
derived  primarily  as  outgrowths  from  the  lower  end  of  the  Wolffian  duct  (PI. 
16,  b;  Figs.  105,  109).  About  the  fourth  week  a  diverticulum  grows  from 
the  hinder  end  of  the  duct  forward  and  dorsally  into  a  mesodermic  area  close 
to  and  behind  the  lower  end  of  the  Wolffian  bod}'.  The  tube  thus  formed  is 
the  primitive  ureter,  which  extends  within  the  mesodermic  tissue,  where,  after 
expanding  into  the  immature  pelvis,  it  breaks  up  into  a  number  of  tubes  cor- 
responding with  the  calices,  from  which  pass  epithelial  cylinders  representing  the 
epithelial  portions  of  the  uriniferous  tubules.  Later  the  vascular  mesoderm 
contributes  the  primitive  glomeruli,  which  meet  the  expanded  ends  of  the 
tubules  and  take  part  in  the  further  development  of  the  Malpighian  bodies  of 
the  kidney.  By  the  end  of  the  second  month  the  definite  character  of  the 
renal  structure  has  become  established.  As  the  permanent  organ  increases  in 
size  and  functional  importance  the  Wolffian  body  rapidly  atrophies,  so  that  by 
the  end  of  the  fourth  month  its  activity  as  an  excretory  organ  has  disappeared, 
the  parts  still  remaining  bearing  relations  to  the  sexual  apparatus  alone. 

The  bladder  is  the  persistent  and  expanded  proximal  portion  of  the  allan- 
toic duct  which  retains  its  lumen,  while  that  of  the  distal  segment  of  the  same 
duct  loses  its  lumen  about  the  fifth  week,  becoming  converted  into  a  solid 
fibrous  cord,  the  urachus,  which  stretches  from  the  summit  of  the  urinary  blad- 
der to  the  umbilicus.  The  Madder  therefore  differs  from  the  kidney  and  the 
ureter  in  possessing  a  lining  derived  from  the  entoderm,  and  in  not  being 
entirely  of  mesodermic  origin. 

The  formation  of  the  internal  generative  organs  consists  of  two  distinct 
developmental  processes,  the  development  of  the  sexual  glands  and  that  of 
their  excretory  passages.  At  the  end  of  the  first  month  the  mesothelial  cover- 
ing of  the  Wolffian  bodies,  along  their  inner  borders,  shows  an  extended  area 
of  thickening  and  proliferation,  the  resulting  elevated  bands,  the  genital  ridges, 
being  the  earliest  traces  of  the  sexual  glands.  For  a  short  time  these  glands 
are  of  an  indifferent  type  (Fig.  110),  the  differential  characteristics  of  the  two 
sexes  not  being  manifested,  seemingly,  for  some  days  ;  the  primitive  male  gland 
then  exhibits  a  disposition  to  form  networks  of  tortuous  anastomosing  cell- 
cords  (Fig.  Ill),  the  forerunners  of  the  seminiferous  tubules  ;  the  female  gland, 
on  the  contrary,  possesses  a  larger  number  of  the  primitive  sexual  cells,  and 
evinces  a  tendency  of  its  elements  to  arrange  themselves  into  groups  in  which 
the  larger  primitive  ova  become  central  figures.  Microscopical  examination  of 
the  sexual  primitive  glands  even  at  the  end  of  the  fifth  week  is  capable  of  dis- 
tinguishing the  future  sex  of  the  being.     It  is  highly  probable,  as  emphasized 


PHYSIOLOGY    OF  PREGNANCY. 


123 


byNagel,  that  inherent  sexual  differences  exist  in  the  glands  from  their  earliest 
appearance,  and  that  the  recognition  of  the  indifferent  stage  depends  largely 

upon    our    imperfect    appreciation    of 
these  distinctions. 

The  development  of  the  second  part 
of  the  sexual  apparatus,  the  system  of 
excretory  passages,  depends  upon  the  ap- 
propriation and  modification  of  already 
existing  tubes,  the  tubules  of  the  Wolff- 
ian body,  the  Wolffian  duct,  and  the 


Fig.  110.— Diagram  representing  the  indifferent 
stage  in  the  development  of  the  generative  organs 
(modified  from  Allen  Thompson). 


Fig.  111. — Internal  generative  organs  of  a  male 
fetus  of  about  fourteen  weeks  (Waldeyer) :  t,  tes- 
ticle ;  e,  epididymis ;  w',  Wolffian  duct ;  w,  lower 
part  of  Wolffian  body :  g,  gubernaculum  testis. 


Miillerian  duct.     The  fate  of  these  structures  varies  with  sex.     In  the  female 
(Fig.  112)  the  Miillerian  ducts  are  most  important;  they  develop  into  the  ovi- 


Fig.  112.— Diagram  illustrating  changes  taking 
place  in  development  of  female  generative  organs 
(modified  from  Allen  Thompson). 


Fig.  113.— Internal  organs  of  a  female  fetus  of 
about  fourteen  weeks  (Waldeyer) :  o,  ovary ;  e,  epo- 
ophoron  or  parovarium  ;  w\  Wolffian  duct;  m,  Miil- 
lerian duct ;  w,  lower  part  of  the  Wolffian  body. 


ducts,  and,  after  becoming  fused,  into  the  uterus  and  the  vagina,  while  tlie 
Wolffian  bodies  and  duct  give  rise  at  best  to  atrophic  structures.     The  Wolff- 


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AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 


ian  body  in  the  female  contributes  the  transverse  tubules  of  the  parovarium  or 
epoophoron,  the  upper  part  of  the  Wolffian  duct  remaining  as  the  head-tube  of 
the  same  atrophic  organ  (Fig.  113).  When  the  Wolffian  duct  persists  it  con- 
stitutes Gartner's  duct.     In  the  male  subject  (Fig.  114),  on  the  contrary,  the 


Fig.  114.— Diagram  illustrating  changes  taking  place  in  development  of  male  generative  organs  (modified 
from  Allen  Thompson). 

Wolffian  tubules  and  the  Wolffian  duct  contribute  the  important  system  of 
excretory  tubes  represented  by  the  vasa  efferentia,  the  coni  vasculosi,  the  tube 
of  the  epididymis,  and  the  vas  deferens,  while  the  Miillerian  duct  is  atrophic, 
its  extreme  ends  alone  remaining  as  the  sessile  hydatid  of  Morgagni,  closely 
connected  with  the  globus  major  of  the  epididymis,  and  as  the  sinus  pocularis 
or  uterus  masculinus,  opening  into  the  prostatic  portion  of  the  iu-ethra. 

The  atrophic  tubules  of  the  lower  segment  of  the  Wolffian  body  in  both 
sexes  contribute  rudimentary  organs,  the  paradidymis  and  the  paroophoron 
respectively,  which  consist  of  a  few  tortuous  tubules  situated  in  the  epididymis 
and  in  the  broad  ligament  near  the  parovarium.  The  stalked  hydatids  of 
Morgagni,  which  are  common  to  both  sexes,  probably  represent  portions  of 
the  atrophic  head-kidney  and  its  duct. 

The  External  Genitcd  Organs. — Until  the  ninth  or  tenth  week  the  external 
genitalia  afford  no  positive  information  as  to  sex,  since  these  parts  until  this 
time  represent  a  practically  indifferent  type  (Fig.  115). 

Up  to  the  sixth  week  the  external  openings  of  the  gut  and  of  the  urinary 
tract  are  received  within  a  common  cloacal  recess  whose  recto-urogeuital  orifice 
is  surmounted  by  a  small  conical  elevation,  the  genital  tubercle;  the  lower  and 
posterior  surface  of  this  eminence  is  divided  by  a  furrow,  the  genital  groove, 
bounded  by  thickened  lips,  the  genital  folds ;  outside  the  latter  a  less  con- 
spicuous elliptical  fold  constitutes  the  genital  ridges.  The  end  of  the  genital 
tubercle  enlarges  and  forms  a  knob-like  expansion,  the  primitive  glans  either 
of  the  future  penis  or  of  the  clitoris.     Toward  the  end  of  the  second  month 


PHYSIOLOGY   OF  PREGNANCY. 


125 


the  imperfectly  formed  septum  between  the  rectum  and  the  urinogenital  pas- 
sage reaches  perfection,  whereby  the  complete  separation  between  the  aliment- 
ary and  gen i to-urinary  canals  is  effected. 

In  the  male  (Fig.  115,  C,  E,  g)  the  genital  tubercle  elongates  to  form  the  penis, 
while  the  lips  of  the  genital  furrow  on  its  under  surface  unite  to  form  the 


Fig.  115.— Development  of  external  genital  organs  of  human  fetus  (Ecker-Zlegler  models) :  A,  B,  indif- 
ferent type,  fifth  to  eighth  week :  do,  cloaca ;  I,  lower  limb ;  gt,  genital  tubercle ;  gr,  genital  ridge ;  gf, 
genital  fold ;  gg,  genital  groove.  C,  E,  G,  organs  of  male  type :  gp,  glans  penis ;  gr,  genital  ridge ;  gf,  geni- 
tal fold :  gg,  genital  groove  ;  per,  perineum  ;  a,  anus ;  pr,  prepuce  ;  8,  scrotum ;  r,  raphe.  D,  F,  H,  organs 
of  female  type :  d,  clitoris ;  gr,  genital  ridges ;  gf,  genital  folds ;  ag,  urinogenital  fissure  ;  per,  perineum ; 
a,  anus ;  pc,  prepuce  of  clitoris  ;  l.maj,  labia  majora  ;  l.min,  labia  minora  ;  v,  vestibule ;  vag,  vagina. 

penile  portion  of  the  urethra ;  coincidently,  the  closure  of  the  edges  of  the 
urinogenital  passage  takes  place,  the  tube  thus  formed  becoming  continuous 
with  the  anterior  part  of  the  urethra  just  formed.  The  primitive  genital 
ridges  or  outer  genital  folds  grow  together  and  eventually  form  the  scrotum, 
into  which  the  testicles  descend  shortly  before  birth. 

In  the  female  (Fig.  115,  D,  F,  h)  the  genital  tubercle  remains  relatively  small 


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and  becomes  the  clitoris  ;  the  genital  furrow  remains  open,  the  bounding  genital 
folds  forming  the  labia  minora  or  the  nyruphse,  and  the  external  folds  forming 
the  labia  majora.  At  first  the  clitoris  is  disproportionately  large,  but  later  it 
becomes  overshadowed  by  the  rapidly  growing  labia.     Usually,  by  the  end  of 


Notochord.  Somite.     Gut  entoderm. 

Fig.  116. — Transverse  section  of  a  sixteen  and  a  half  day  sheep  embryo  possessing  sis  somites  (Bonnet). 

the  third  month  the  external  sexual  characteristics  of  the  fetus  are  established 
beyond  doubt.  Imperfect  development,  especially  faulty  union,  of  certain 
parts  of  the  primitive  genitalia  produce  the  conditions  which  give  rise  to  ap- 
parent hermaphroditism  :  true  hermaphrodites,  while  not  impossibilities,  are 


Ccil-mass  for 
Wolffian  body. 

M<sothclhtm. 


Notochord. 

Fig.  117. — Transverse  section  of  a  fifteen  and  a  half  day  sheep  embryo  possessing  seven  somites  (Bonnet). 

among  the  rarest  malformations,  since  in  them  the  formation  of  true  sexual 
organs  of  both  sexes  must  take  place  in  the  same  individual. 

10.  Development  of  the  Nervous  System.. — The  initial  stage  in  the  pro- 
duction of  the  great  cerebro-spinal  nervous  axis  is  the  formation  of  the  medul- 
lary folds  and  groove  (Figs.  116,  117),  one  of  the  earliest  of  the  fundamental 


PHYSIOLOGY    OF  PREGNANCY. 


127 


processes  in  the  development  of  the  embryo.     At  the  thirteenth  day  the  neural 
groove  is  widely  open  throughout  its  extent ;  two  days  later,  by  the  beginning 

of  the  third  week,  the  groove  has  become 
converted  into  a  closed  canal  by  the  ap- 
proximation of  the  thickened  neural 
plates  along  the  dorsal  mid-line.  The 
cephalic  extremity  of  the  neural  canal, 


Middle  brain-vesicle 
Posterior  brain-vesicle 


Fore-b. 
Primary  optic  vesiclt 
Stalk  of  optic  vesicl, 


Cephalic  fle. 


Fig.  IIS.— Diagrams  illustrating  the  primary  and  sec- 
ondary segmentation  of  the  brain-tube  (Bonnet). 


Cerebral  portion  of 
pituitary  body. 

Fig.  119.— Diagram  showing  relations  of  brain- 
vesicles  and  flexures  (Bonnet). 


even  before  closure,  becomes  expanded  into  three  primary  brain-vesicles,  the 
anterior,  the  middle,  and  the  posterior.  The  anterior  and  the  posterior  of 
these  vesicles  very  soon  subdivide  into  secondary  compartments,  the  arrange- 
ment of  the  brain-segments  then  being,  from  before  backward,  the  fore-brain, 
the  inter-brain,  the  mid-brain,  the  hind-brain,  and  the  after-brain  (Fig.  118). 

Coincidently  with  these  changes  the  cerebral  axis  has  suffered  marked  de- 
flection (Fig.  119)  from  its  original  almost  straight  condition.  By  the  fifteenth 
clay  the  cranial  flexure  is  strongly  pronounced,  a  bend  of  almost  90°  taking 
place  opposite  the  mid-brain  (Fig.  120,  a).  During  the  fourth  week  further 
marked  changes  appear;  the  bend  opposite  the  mid-brain,  or  mesencephalic 
flexure,  has  increased  almost  to  180°,  so  that  the  ventral  surfaces  of  the  inter- 
brain  and  the  hind-brain  lie  nearly  in  contact  (Fig.  120,  b).  The  junction 
of  the  brain  and  the  spinal  cord  is  marked  by  the  cervical  flexure,  which 
forms  an  angle  of  about  90°.  A  third  bend,  the  metencephalic  or  frontal  flex- 
ure, appears  opposite  the  primitive  cerebellum  and  the  pons,  and  has  its  con- 
vexity directed  ventrally  or  in  a  manner  opposite  to  the  disposition  of  the 
other  curves  (Fig.  120,  c). 

The  development  of  the  individual  parts  of  the  brain  depends  largely 
upon  local  thickenings  of  parts  of  the  walls  of  the  cerebral  vesicles,  whereby 
areas  of  notable  thickness  are  produced,  as  in  those  which  give  rise  to  the 
corpus  striatum  and  the  optic  thalamus ;  the  cleavage  of  the  fore-brain  and  the 
ingrowth  of  connective-tissue  structures  accompanying  the  growth  of  the 
primitive  falx  likewise  exert  a  profound  influence  in  shaping  the  parts  around 


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the  lateral  and  third  ventricles.     The  appearance  of  such  commissural  bands 
as  the  corpus  callosum  and  the  fornix  still  further  modifies  the  adjacent  struc- 


X^^^^^^t 


ol  o  fj    u  ol  p        ff  m 

Fig.  120.— Brains  of  human  embryos  from  reconstructions  by  His.  A,  brain  from  fifteen  day  embryo  ; 
B,  from  three  and  a  half  week  embryo  ;  C,  from  seven  and  a  half  week  fetus :  fb,  ib,  mb,  hb,  ab,  fore-,  inter-, 
mid-  hind-,  and  after-brain  vesicles  ;  o,  optic  vesicle ;  ov,  otic  vesicle ;  in,  infundibulum ;  m,  mammillary 
process;  pf,  pontine  flexure;  IVv,  fourth  ventricle;  nk,  cervical  flexure;  ol,  olfactory  lobe;  b,  basilar 
artery  ;  p,  pituitary  recess. 

tures.     The  brain-vesicle  undergoing  least  change  is  the  mid-brain,  since  its 
walls  remain  uncleft  and  retain  their  primary  relations  to  the  enclosed  canal. 


ma      j>  o!f  est  ol/ 

Fig.  121.— A,  mesial  section  through  brain  of  a  human  fetus  of  two  and  a  half  months  (His) :  eft,  cere- 
bral hemisphere ;  o,  optic  thalamus  ;  fin,  foramen  of  Monro ;  olf,  olfactory  lobe ;  p,  pituitary  body ;  mo, 
medulla  oblongata;  eg,  corpora  quadrigemina ;  cb,  cerebellum.  B,  brain  of  human  fetus  of  three  months 
(His) :  ol/,  olfactory  lobe ;  est,  corpus  striatum  ;  cq,  corpora  quadrigemina ;  cb,  cerebellum ;  mo,  medulla 
oblongata. 

The  relative  position  of  the  mid-brain,  however,  undergoes  great  change,  its 
original  situation  as  the  highest  part  of  the  entire  encephalon  being  gradually 


DEVELOPS 


lafte'JT^m1''^?  <ret;™st™<;ted>  of  twenty-six  aays,  viewed  from  the  left  side;  magnified  25  diameters 
u£7&^'\a^Xl%1%ffl£?  P0UCheS;  r'th^^y;  ^nchus^/liveY;'^- 


THE   FETUS. 


Plate  16. 


Human  embryo,  same  as  preceding  figure,  but  taken  at  a  deeper  plane  (after  F.  Mall):  H,  diverticulum 

contributing  the  oral   portion  of  the  pituitary  body;    M  (above),  primitive   mouth;    1,  •'    3,  4,  pharvngca] 
pouches;   B,  bronchus;   P,  pancreas;   I,  liver;  If,  B.,  Wolffian  body;   II'.  I)..  Wolffian  duct;  K,  kidney;  c, 

—timunicate  ;  P,  papilliform  projection  into  Tower 


PHYSIOLOGY   OF  PREGNANCY. 


129 


appropriated  by  the  enormously  developed  cerebral  mantle  formed  by  the  rapid- 
growing  cerebral  hemispheres;  in  consequence  of  the  covering  in  of  the  mid- 
brain thus  effected,  the  derivatives  of  this  segment,  as  the  corpora  quadri- 
gemina,  occupy  a  position  in  the  base  of  the  adult  brain  instead  of  their 
morphologically   normal   place.       The  extent   to   which   the  cerebral   mantle 


Fig.  122.— Fetal  brain  at  the  beginning  of  the  eighth  month  (Mihalkovics) :  A,  superior,  B,  lateral,  C, 
mesial  surface :  E,  fissure  of  .Rolando ;  pre,  precentral  fissure  ;  Sy,  Sylvian  fissure  ;  intp,  interparietal  fissure  ; 
poc,  parietooccipital  fissure  ;  ptt,  parallel  fissure  ;  callm,  calloso-marginal  fissure ;  unc,  uncus  ;  calc,  calca- 
rine  fissure. 

covers  the  remaining  parts  of  the  encephalon,  including  the  cerebellum,  is 
distinctive  of  the  human  brain  (Figs.  121,  122). 

The  inter-brain  undergoes  great  differentiation,  its  derivatives  forming  numer- 
ous highly  specialized  organs,  among  which  are  the  eyes  and  the  pineal  and 
pituitary  bodies.  For  the  complicated  details  of  the  development  of  the 
various  parts  of  the  brain  the  reader  must  be  referred  to  the  special  works  on 
embryology.  The  following  table,  however,  modified  from  Hertwig,  will  serve 
as  a  general  indication  of  the  genetic  relations  existing  between  the  more  im- 
portant parts  of  the  encephalon  and  the  primary  cerebral  segments : 
Development  op  the  Human  Brain. 


Primary 
Vesicles. 

Secondary 
Vesicles. 

Floor. 

Roof.                  Sides. 

Cavity. 

I. 
Anterior 

1. 
Fore-brain. 

Anterior  perfor- 
ated    spaces ; 
olfactory 
lobes. 

Great  cerebral  mantle;  corpus 
callosum;  fornix. 

Lateral 
ventri- 
cles. 

"  Brain-mantle. 

brain- 
vesicle. 

Inter-brain. 

Optic     chiasm ; 
tnber       cine- 
reum ;  infun- 
dibulum;  cor- 
pora mammil. 

Pineal      body ; 
posterior  com- 
missure ;    ve- 
lum interpos- 
ituni. 

Optic  thalami. 

Third  ven- 
tricle. 

II. 

Middle 
primary 
brain- 
vesicle. 

3. 
Mid-brain. 

Cerebral  pedun- 
cles ;        poste- 
rior perforated 
lamina. 

Corpora    quad- 
rigemina. 

Geniculate 
bodies ; 
brachia. 

Aqueduct 
of    Syl- 
vius. 

B. 

III. 
Posterior 
primary 

4. 
Hind-brain. 

Pons  Varolii. 

Anterior    med- 
ullary velum ; 
cerebellum  ; 
posterior  med- 
ullary velum. 

Superior   and 
middle    pe- 
duncles    of 
cerebellum. 

Fourth 
ventri- 
cle. 

Brain-stalk. 

brain- 
vesicle, 

5. 
After-brain. 

Medulla  oblon- 
gata. 

Thin     covering 
of      posterior 
part  of  fourth 
ventricle. 

Inferior     pe- 
duncles   of 
cerebellum. 

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The  spinal  cord  is  formed  primarily  by  the  thickening  of  the  lateral  wall 
of  the  neural  tube,  the  latter  becoming  reduced  to  a  narrow  passage,  later  the 
central  canal.  At  first  gray  matter  alone  exists,  but  with  the  formation  of  the 
nerve-fibres  the  white  tracts  appear  (Fig.  1 23).     The  nerve-fibres  connected 


Outer  medullary  zone      Central  canal.       Notochord.  Ventral  c 

Fig.  123.— Transverse  section  of  developing  spinal  cord  of  a  twenty-two  day  sheep  embryo  (Bonnet). 

with  the  spinal  cord  differ  in  origin  according  to  their  function  whether  they 
are  motor  or  sensory,  the  former  proceeding  as  outgrowths  from  the  nerve-cells 
within  the  cord,  the  latter  as  processes  from  the  cells  of  the  spinal  ganglia; 
these  latter  centres,  in  addition  to  the  sensory  fibres  passing  into  the  cord,  send 
to  the  periphery  fibres  by  which  sensory  impressions  are  conveyed.  The  sym- 
pathetic nervous  system  originates  from  the  spinal  ganglia,  from  which  portions 
are  separated  as  the  origin  of  the  sympathetic  ganglia.  It  may  therefore  be 
accepted  as  an  axiom  that  all  nerve-fibres  are  produced  as  direct  outgrowths 
from  pre-existing  nerve-cells,  and,  further,  that  all  portions  of  the  great 
nervous  system  may  be  referred  to  the  primary  neural   folds. 

11.  Development  of  the  Organs  of  Special  Sense. — The  history  of  the 
specialized  organs  of  touch,  taste,  and  smell,  as  represented  by  the  various 
forms  of  tactile  nerve-endings,  such  as  the  corpuscles  of  Meissner,  Vater,  etc., 
the  taste-buds,  and  the  Schneiderian  mucous  membrane,  belongs  to  a  consider- 
ation of  the  histogenesis  of  these  structures  rather  than  to  a  brief  outline  of 
salient  features  in  general  development ;  suffice  it  here  to  add  that  the  organs 
of  taste  and  smell  consist  essentially  of  tissue  which  has  become  specialized 
into  neuro-epithelium,  the  perceptive  elements  consisting  of  modified  epithelial 
cells  bearing  close  relations  to  the  nerve-fibres.  The  various  forms  of  tactile 
corpuscles  receive  more  or  less  highly  developed  sheaths  from  mesodermic 
tissues.  The  organs  of  sight  and  of  hearing,  on  the  contrary,  claim  greater 
attention  on  account  of  the  profound  embryological  processes  instituted  in 
their  formation. 

The  development  of  the  eye  consists  essentially  in  the  formation  of  two 


PHYSIOLOGY   OF  PREGNANCY. 


131 


ectoderrnic  epithelial  pouches,  the  optic  vesicle  and  the  lens-sac,  around  which 
the  adjacent  mesoderm  differentiates  into  vascular  and  fibrous  envelopes.     The 


.  111k.  fpfy'*. ''.  ■  il 


Fig.  124.— Section  through 
head  of  ten  day  rabbit  em- 
bryo, exhibiting  primary  optic 
vessel  (0)  protruding  from 
fore-brain  (B)  and  coming  in 
contact  with  surface  ectoderm 
(e) ;  m,  surrounding  mesoderm 
(Piersol). 


Fig.  125. — Section  through 
developing  eye  of  eleven  day 
rabbit  embryo  (Piersol) :  B, 
fore-brain  connected  by  stalk 
with  optic  vesicle  (o),  whose 
anterior  wall  is  partly  invagi- 
nated;  I,  thickened  and  de- 
pressed lens-area. 


Fig.  126.— Section  through  developing 
eye  of  eleven  and  a  half  day  rabbit  em- 
bryo (Piersol) :  B,  fore-brain  connected 
with  optic  vesicle  (o),  nearly  effaced  by 
apposition  of  invaginated  anterior  seg- 
ment (r)  with  posterior  wall  ( p) ;  I,  lens- 
sac  completely  closed  and  separated  from 
ectoderm;  t,  tissue  within  secondary  optic 
cup  derived  from  surrounding  mesoderm. 


first  trace  of  the  visual  organs  appears  very  early — at  the  fifteenth  day — as  the 

conspicuous  optic  vesicles  (Fig.  128), 
which  are  formed  as  lateral  evagina- 
tions  from  the  hinder  part  of  the  ante- 
rior primary  brain-vesicle  ;  later,  when 
the  optic  vesicle  opens  into  the  cerebral 
cavity  by  means  of  the  optic  stalk,  the 
latter  communicates  with  the  inter- 
brain.  The  original  optic  vesicle  soon 
exhibits  indentation  of  its  anterior  wall 
(Fig.  125),  the  invagination  progress- 


Fig.  127. — Section  through  developing  eye  of 
thirteen  day  rabbit  embryo  (Piersol) :  e,  ectoderm ; 
I,  lens,  consisting  of  anterior  nucleated  division 
representing  thin  front  wall  of  lens-sac,  and  greatly 
thickened  posterior  division  completely  filling  cav- 
ity of  sac  by  elongated  fibres  whose  nuclei  present 
crescentic  zone  (z) ;  p,  posterior  pigmented  layer ; 
r,  specialized  anterior  retinal  layer;  i,  point  where 
layers  of  optic  vessels  become  continuous;  n,  ex- 
treme peripheral  section  of  tissue  of  primitive 
optic  nerve  connected  with  vascular  tunic  (»)  occu- 
pying posterior  surface  of  lens ;  m,  surrounding 
mesoderm,  which  (at  t)  grows  between  lens  and 
retina. 


Fig.  128. — A,  brain  of  two  day  chick  embryo; 
B,  brain  of  human  embryo  of  three  weeks  (His) 
Shows  the  development  of  the  optic  vesicles  and 
brain-vesicles:  Jb,  fore-brain;  ib,  inter-brain;  on, 
optic  vesicles. 


ing  until   the  displaced  layer  comes  in  contact  with  the  posterior  and  outer 


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undisturbed  segment.  The  cavity  of  the  original  vesicle  is  now  represented 
by  the  hemispherical  cleft  between  the  two  layers.  The  cavity  newly  formed 
by  the  invagination  of  the  primary  vesicle  becomes  the  optic  cup,  and  repre- 
sents the  space  later  occupied  by  the  crystalline  lens  and  the  vitreous  body. 

Coincident!}'  with  the  changes  of  the  optic  vesicle,  the  surface  ectoderm  at 
first  exhibits  a  depression  lined  by  thickened  cells ;  this  recess  or  pit  rapidly 


■  sp 


md — 


ais 


X 


4 


fj. 


Fig.  129.— Human  embryo  of  about  twenty-eight  days  (His):  I-V,  brain-vesicles;  /', /2, /3,  /*, 
cephalic,  cervical,  dorsal,  and  lumbar  flexures;  op,  eye;  ot,  optic  vesicle;  ol,  olfactory  pit;  mx,  md,  max- 
illary and  mandibular  processes  of  first  visceral  arch;  sp,  sinus  precervical ;  ft1,  ft2,  heart;  I,  P,  limbs; 
ate,  allantoic  stalk;  eft,  villous  chorion. 

deepens  and  expands,  and  finally  becomes  the  closed  and  isolated  lens-sac,  lying 
within  the  mouth  of  the  optic  cup,  which  it  largely  fills  (Fig.  126). 

The  fate  of  the  layers  composing  the  optic  cup,  briefly  stated,  is  the  forma- 
tion of  the  various  parts  of  the  retinal  tract,  the  outer  and  posterior  layer 
becoming  the  characteristic  sheet  of  retinal  pigment ;  the  blood-vessels  and  the 


PHYSIOLOGY    OF  PREGNANCY. 


13:2 


connective-tissue  elements  of  the  retina  are  secondary  ingrowths  (Fig.  127). 
The  hinder  wall  of  the  lens-sac  undergoes  great  proliferation,  growth,  and 
thickening,  and  eventually  fills  the  entire  sac,  the  lens  then  continuing  as  a 
solid  body  composed  of  specialized  epithelial  elements. 

The  surrounding  mesoderm  contributes  the  blood-vessels,  the  vitreous  body, 
the  choroid,  and  the  sclerotic  coat,  including  the  iris  and  the  cornea  with  the 
exception  of  the  anterior  epithelium  of  the  latter,  which  is  ectodermic  in 
origin.  The  eyelids,  which  appear  toward  the  end  of  the  second  month,  are 
developed  as  duplicatures  of  skin  above  and  below  the  eye  ;  about  the  end  of 
the  third  or  the  beginning  of  the  fourth  month  the  lids  meet  and  unite,  the 
eyes  remaining  closed  until  near  the  end  of  gestation,  when  the  lids  perma- 
nently separate. 

The  ear  includes  several  distinct  developmental  processes,  since  the  genesis 
of  the  auditory  apparatus  of  man  includes  the  formation  of  the  external,  the 
middle,  and  the  internal  ear. 

The  external  ear  is  closely  related  to  the  history  of  the  first  outer  visceral 
furrow,  the  external  canal  being,  with  some  minor  variations,  the  representa- 
tive of  this  cleft,  and  the  expanded  parts  constituting  its  pinna,  resulting 
from  the  fusion  and  metamorphosis  of  the  auditory  tubercles  (Fig.  129)  sur- 
rounding the  outer  end  of  the  visceral  furrow. 

The  middle  ear  is  formed  by  the  persistence  and  further  expansion  of  the 
first  pharyngeal  pouch,  hence  possesses  an  entodermic  lining.  The  tympanic 
membrane  includes  contributions  from  all  three  layers,  its  outer  epithelium 
being  ectodermic,  its  inner  epithelium  entodermic,  and  its  fibrous  tissue  meso- 
dermic,  in  origin. 

The  internal  ear  consists  of  the  morphologically  older  ectodermic  portion, 
which    is    represented    by   the  complicated    membranous    labyrinth,   and   the 
surrounding  mesodermic  envelope,  which   becomes  the  bony  capsule,  and  the 
connective-tissue     structures     included 
between  the  osseous  and  the  membra- 
nous labyrinth. 

The  earliest  appearance  of  the  ears 
takes  place  about  the  fifteenth  day, 
when  on  each  side  of  the  hind-brain  a 
depression  lined  by  thickened  ectoderm 
(Fig.  130),  the  otic  pit,  is  formed.  Al- 
most immediately  these  pits  become 
converted  into  sacs,  the  otic  vesicles,  by 
the  closure  of  their  mouths,  and  soon 
lose  all  'onnection  with  the  ectoderm, 
lying  entirely  surrounded  by  meso- 
dermic tissue  some  little  distance  be- 
neath the  free  surface.    The  otic  vesicle   bi°0(i-vessei. 

appears  pyriform,  that  part  corresponding  with  the  closed  mouth  becoming  ex- 
tended ;  this  elongation  soon  becomes  more  pronounced,  so  that  the  now  some- 


FiG.  ISO.— Section  through  developing  ear  of 
nine  and  a  half  day  rabbit  embryo  (Piersol) :  e, 
ectoderm  thickened  and  invaginated  to  form  au- 
ditory pit  (at  o* ;  m,  surrounding  still  undifferen- 
tiated mesoderm ;  n,  lining  of  neural  tube ;  i>, 


134  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 


Fig.  131.— Diagram  of  fetal  circulation  before  birth  ;  the  arrows  indicate  the  course  of  the  Dloort- 
current :  the  colors  show  the  character  of  the  blood  carried  by  the  different  vessels. 


PHYSIOLOGY    OF  PREGNANCY. 


135 


?ig.  13:2—  Diagram  of  circulation  after  birth  ;  the  ductus  yen 
ductus  arteriosus  are  now  closed  aud  no  longer  transmit 


foramen  ovale,  and  the 
af  the  blood-current. 


136 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


what  flattened  sac  presents  a  conspicuous  outgrowth,  the  recessus  labyrinthi 
(Fig.  133,  a).    _ 

The  otic  vesicle  assumes  greater  irregularity  on  account  of  the  appearance, 
during  the  fifth  week,  of  a  blunt  diverticulum,  anteriorly  and  ventrally 
directed,  which  is  the  earliest  trace  of  the  future  membranous  cochlea,  and, 
shortly  after,  of  dorsal  projections  on  its  outer  side,  which  foreshadow  the 
semicircular  canals  (Fig.  133,  b,  c).  Before  the  end  of  the  fifth  month,  the 
chief  compartment  of  the  vesicle,  by  this  time  of  considerable  size,  undergoes 


Fig.  133.— Development  of  the  membranous  labyrinth  of  the  human  ear  (W.  His,  Jr.).  A,  left  laby- 
rinth of  embryo  of  about  four  weeks,  outer  side :  v,  e,  vestibular  and  cochlear  portions ;  rl,  recessus 
labyrinthi.  B,  left  labyrinth  with  parts  of  facial  and  auditory  nerves  of  embryo  of  about  four  and  a  half 
weeks  :  rl,  recessus  labyrinthi ;  sse,  psc,  esc,  superior,  posterior,  and  external  semicircular  canals;  s,  sac- 
cule; c,  cochlea;  vn,/n,  vestibular  and  facial  nerves;  vg,  eg,  gg,  vestibular,  cochlear,  and  geniculate  gan- 
glia. C,  left  labyrinth  of  embryo  of  about  five  weeks,  from  without  and  below  ;  labelling  as  in  preceding 
figure. 

subdivision  by  the  formation'of  a  constricting  fold  into  a  dorsal  division,  the 
primitive  utriculus,  and  a  ventral  division,  the  primitive  sacculus.  The  rudi- 
mentary semicircular  cauals  and  the  primitive  cochlear  duct  open  respectively 
into  the  utricle  and  the  saccule.  The  recessus  labyrinthi  has  become  mean- 
while greatly  elongated,  and  its  proximal  end  cleft  into  diverging  tubes  at  the 
formation  of  a  septum.  These  limbs  of  the  recess  open  into  different  spaces, 
one  entering  into  the  saccule,  the  other  into  the  utricle. 

The  permanent  arrangement  is  now  established  whereby  communication 
between  the  divisions  of  the  membranous  vestibule,  the  utricle  and  the  sac- 
cule, is  effected  only  by  the  indirect  passage  through  the  limbs  of  the  ductus 
cndolymphaticus.  The  primary  otic  vesicle  thus  becomes  the  complicated 
membranous  labyrinth,  and  the  ectodermic  epithelial  lining  undergoes  differ- 
entiation in  the  formation  of  the  highly  specialized  structures,  as  the  organ  of 
Corti  and  the  maculse  acusticse,  for'the  perception  of  transmitted  stimuli. 

The  mesoderm  immediately  surrounding  the  membranous  labyrinth  later 
undergoes  important  changes,  whereby  the  tissue  next  the  epithelial  structures 
is  converted  into  the  connective  tissue  enveloping  and  supporting  the  delicate 


PHYSIOLOGY   OF  PREGNANCY.  137 

epithelial  labyrinth,  while  the  tissue  slightly  removed  gives  rise  to  the  periotic 
cartilaginous  capsule  which  later  is  replaced  by  bone.  The  important  spaces 
occupied  by  the  perilymph  are  formed  relatively  late,  since  they  arise  by  the 
breaking  down  and  channelling  of  the  mesoderm  surrounding  the  epithelial 
tubes.  In  the  cochlea,  for  example,  the  ductus  cochlearis,  with  its  epithelial 
lining,  represents  genetically  the  oldest  part,  while  the  scala  vestibuli  and  the 
scala  tympani  are  of  more  recent  origin,  since  they  are  formed  by  partial  dis- 
appearance of  the  mesodermic  tissues. 

2.  Physiology  of  the  Fetus. 

Nutrition  and  Growth. — It  is  evident  that  the  life  of  the  ovum,  what- 
ever its  character,  whether  vertebrate  or  invertebrate,  picean,  amphibian, 
reptilian,  avian,  or  mammalian,  can  only  be  maintained  when  the  fundamental 
necessities  of  life — adequate  supplies  of  oxygen,  water,  and  suitable  nourish- 
ment— are  provided.  The  ovum  and  the  early  embryo  being  without  means  of 
securing  these  advantages,  such  provisions  must  be  ensured  by  the  arrangement 
of  the  immediate  environments,  whether  these  be  within  the  maternal  tissues 
or  within  the  protecting  structures  of  the  shell  or  the  surrounding  medium. 

The  loss  of  yolk,  which  there  is  good  reason  for  believing  the  mammalian 
ovum  has  suffered  during  its  evolution,  is  compensated  by  the  nutritive  mate- 
rials supplied  to  the  developing  ovum  by  the  adherent  discus  proligerus,  and 
by  the  secretions  of  the  oviduct  and  uterus  which  are  taken  into  the  interior 
of  the  egg  by  osmosis  through  the  zona  pellucida  and  the  primitive  chorion. 

The  Fetal  Circulations. — The  earliest  circulation,  the  vitelline  (PI.  15),  is 
well  established  during  the  third  week.  The  blood  passes  from  the  network  of 
the  vascular  area,  by  means  of  the  large  vitelline  or  omphalo-mesenteric  veins, 
into  the  sinus  venosus,  and  then,  after  mingling  with  the  blood  returned  by 
the  systemic  veins  from  the  body  of  the  embryo,  into  the  auricular  segment 
of  the  young  heart.  From  the  anterior  or  arterial  end  of  this  organ  the 
blood  is  carried  by  the  truncus  arteriosus  into  the  aortic  arches,  hence  into  the 
primitive  aortse,  a  small  portion  passing  into  vessels  supplying  the  embryo, 
while  the  greater  part  enters  the  vitelline  arteries  and  once  more  gains  the 
vascular  area. 

The  development  of  the  allantoic  vessels  and  the  placental  circulation 
necessitates  additional  blood-currents,  in  the  direction  of  which  the  now 
rapidly  developing  heart  and  liver  exert  an  important  influence.  For  a  time 
all  the  blood  returning  from  the  placenta  passes  through  the  liver  before 
reaching  the  heart ;  later,  when  the  hepatic  capillaries  can  no  Jonger  accommo- 
date the  entire  placental  circulation,  the  ductus  venosus  is  established. 

During  the  later  months  of  gestation  the  so-called  "  fetal  circulation  ''  (Figs. 
131,  132)  presents  the  following  details:  After  purification  by  the  respiratory 
interchanges  carried  on  within  the  placenta  by  association  with  the  maternal 
circulation,  the  blood  is  conveyed  by  the  single  umbilical  vein  to  the  under  sur- 
face of  the  liver  ;  here  the  current  divides,  one  part  joining  the  venous  blood 
within  the  portal  vein  collected  from  the  intestines,  and  traversing  the  hepatic 


138  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

capillaries  to  reach  the  hepatic  veins,  the  other  part  passing  into  these  vessels 
directly  by  means  of  the  ductus  venosus.  On  reaching  the  inferior  cava  the 
arterial  placental  blood,  but  slightly  contaminated  by  admixture  of  the  contents 
of  the  portal  vein,  is  poured  into  the  stream  of  venous  blood  returned  by  the 
inferior  cava  from  the  lower  parts  of  the  body,  and  is  carried  into  the  heart  as 
part  of  the  mixed  stream.  On  entering  the  right  auricle  a  fold,  the  Eusta- 
chian valve,  directs  the  blood  brought  by  the  inferior  cava  across  the  auricular 
cavity  through  the  foramen  ovale  into  the  left  auricle.  Mingling  with  the 
small  quantity  of  blood  returned  from  the  uninflated  lungs  by  the  pulmonary 
veins,  the  blood-current  passes  through  the  auriculo-ventricular  opening  into 
the  left  ventricle,  by  the  contractions  of  which  it  is  propelled  into  the  aorta, 
and  distributed  by  the  branches  of  that  vessel  to  all  parts  of  the  body. 

The  blood  gathered  from  the  head  and  the  upper  extremities  and  returned 
to  the  right  auricle  by  means  of  the  superior  cava  passes  directly  through  the 
auricle  and  right  auriculo-ventricular  orifice  into  the  right  ventricle,  crossing 
in  its  course  the  blood-stream  entering  by  the  inferior  cava.  The  contractions 
of  the  right  ventricle  send  the  blood  thus  returned  by  the  superior  cava  into 
the  pulmonary  artery  and  on  to  the  lungs.  These  organs,  being  still  unin- 
flated, are  incapable  of  receiving  more  than  a  small  part  of  the  blood  supplied 
from  the  ventricle ;  the  excess,  however,  is  carried  by  means  of  a  newly- 
formed  channel,  the  ductus  arteriosus,  which  extends  from  the  beginning  of 
the  left  pulmonary  artery  to  the  aorta.  The  blood  carried  through  this  canal 
mingles  with  that  descending  the  aorta  ;  on  reaching  the  hypogastric  arteries  a 
large  part  of  the  current  passes  to  the  placenta  for  oxygenation,  only  a  small 
proportion  of  the  stream  continuing  within  the  systemic  arteries  for  the  supply 
of  the  lower  parts  of  the  trunk  and  the  inferior  extremities.  It  will  be 
noticed  that  after  joining  the  current  within  the  inferior  vena  cava  the  blood 
circulating  within  the  fetus  is  nowhere  purely  arterial,  but  is  always  contami- 
nated by  the  admixture  of  blood  already  distributed  to  other  parts. 

The  distinctive  features  of  the  fetal  circulation  are  the  ductus  venosus,  the 
ductus  arteriosus,  the  foramen  ovale,  the  hypogastric  arteries,  and  the  umbili- 
cal vein.  After  birth,  with  the  establishment  of  the  respiratory  function  and 
the  pulmonary  circulation,  the  accessories  to  the  arrangement  of  the  placental 
blood-current  undergo  atrophy  and  largely  disappear.  While  immediately 
instituted,  these  changes  are  not  fully  effected  until  some  time  after  birth. 
Obliteration  of  the  distal  parts  of  the  hypogastric  arteries  first  occurs,  and  is 
usually  completed  by  the  third  or  the  fourth  day  after  birth.  The  ductus  veno- 
sus and  the  umbilical  vein  are  generally  closed  by  the  end  of  a  week.  The  duc- 
tus arteriosus  usually  closes  within  a  few  days,  and  is  completely  impervious 
by  the  third  week  after  birth.  Permanent  closure  of  the  foramen  ovale  is 
delayed  for  some  time,  the  blood  being  excluded  from  the  left  auricle  by  the 
apposition  of  the  edges  of  the  valve,  which  are  kept  in  place  by  the  increasing 
pressure  from  the  left  side  exerted  by  the  blood  returning  from  the  lungs. 
After  a  time  the  edges  of  the  valve  coalesce  with  the  margin  of  the  foramen 
ovale  and  the  opening  becomes  permanently  closed  ;  not  infrequently,  how- 


PHYSIOLOGY   OF  PREGNANCY.  139 

ever,  months  elapse  before  the  union  becomes  complete.  In  case  this  union  is 
never  perfectly  effected,  a  small  communication  may  remain  throughout  life  as 
a  congenital  defect,  of  slight  or  grave  import  depending  upon  the  extent  of 
the  faulty  union. 

The  establishment  of  the  vitelline  circulation,  the  first  one  of  the  embryo, 
marks  the  introduction  of  an  important  nutritive  apparatus  in  animals  possessing 
large  yolks,  which  in  them  constitute  sources  of  nourishment  of  great  conse- 
quence. In  man  and  other  mammals,  however,  the  appearance  of  the  vitelline 
circulation  must  be  regarded  rather  as  the  expression  of  formative  processes 
whose  usefulness  has  largely  disappeared  in  consequence  of  the  profound 
modifications  which  the  diminution  of  yolk  and  the  greater  dependence  on  the 
maternal  tissues  have  witnessed.  While  in  mammals  the  exposure  of  the 
fetal  blood-stream  over  the  extended  walls  of  the  vitelline  sac  or  umbilical 
vesicle  affords  an  opportunity  for  a  limited  exchange  of  gases,  the  amount  of 
nutritive  materials  directly  taken  up  and  appropriated  by  the  embryo  must  be 
very  insignificant. 

The  deficiencies  of  the  vitelline  circulation  in  mammals,  however,  are  com- 
pensated by  the  active  development  of  the  allantoic  vessels  and  their  further 
specialization  into  the  all-important  placental  circulation,  whereby  the  respi- 
ratory and  nutritive  necessities  are  secured  to  the  fetus  throughout  the  last 
two-thirds  of  gestation. 

The  placental  circulation,  by  means  of  which  the  respiratory  interchange  of 
gases  and  the  passage  of  nutritive  substances  from  the  maternal  blood  to  that 
of  the  fetus  is  effected,  is  undoubtedly  the  principal,  and  practically  the  sole, 
source  of  those  substances  necessary  to  maintain  the  life  of  the  developing  ani- 
mal. The  liquor  amnii  has  long  been  regarded  as  an  additional  source  of  nutri- 
tive materials,  in  view  of  the  fact  that  this  fluid  is  undoubtedly  swallowed  by 
the  embryo  and  taken  into  its  intestinal  canal,  as  shown  by  its  presence,  as 
well  as  the  presence  of  hairs  and  epidermal  cells  at  a  later  stage,  within  the 
gut.  The  composition  of  this  fluid,  however,  renders  it  highly  improbable 
that  it  contributes  in  any  appreciable  degree  to  the  nourishment  of  the  fetus, 
containing  as  it  does  nearly  99  per  cent,  of  water.  The  liquor  amnii,  never- 
theless, serves  an  important  purpose  in  supplying  the  water  necessary  for 
the  fetal  tissues,  since  the  latter  must  contain  water  in  excess,  according  to 
Preyer,  in  order  to  extract  the  albumen  and  the  salts  from  the  blood  brought 
by  the  umbilical  vein. 

The  fetal  placental  vessels  convey  albumen,  salts,  and  water  from  the  mater- 
nal blood  into  the  circulation  of  the  fetus,  as  well  as  the  oxygen  absorbed 
by  the  red  blood-cells  during  their  sojourn  in  close  proximity  to  the  sinuses 
filled  with  the  blood  of  the  mother.  The  soluble  salts  probably  pass  from 
the  maternal  blood  into  the  fetal  blood  by  simple  osmosis.  That  the  albu- 
minous substances,  however,  are  so  transferred  is  very  doubtful,  but  the  solution 
of  this  question,  it  must  be  admitted,  so  far  has  been  unsatisfactory.  The 
ingenious  explanation  advanced  by  Rauber,  that  a  physiological  transmigration 
of  leucocytes  from  the  maternal  tissues  into  the  fetus  furnishes  the  means  of 


140  AMERICAN    TEX1-BOOK    OF    OBSTETRICS. 

transportation  of  particles  of  albumin,  fat,  lecithin,  and  similar  substances, 
lacks  confirmation.  By  some  the  evidence  is  regarded  as  strong  that  they 
pass  over  in  the  form  of  soluble  peptones. 

That  substances  in  solution  pass  from  the  maternal  circulation  into  that  of 
the  fetus  has  been  proved  by  direct  experiments  with  iodin  (Gusserow,  Kru- 
kenberg,  Haidlen),  salicylic  acid  (Benicke),  and  potassium  ferrocyanid  (Fehl- 
ing).  The  investigations  of  Zweifel  demonstrated  the  free  and  rapid  passage 
of  chloroform  administered  during  parturition  from  the  maternal  blood  into 
the  umbilical  circulation,  and,  consequently,  the  highly  probable  influence  of 
the  anesthetic  upon  the  fetus.  The  result  of  attempts  to  introduce  substances 
in  a  condition  of  fine  division,  but  not  in  solution,  such  as  vermilion,  India 
ink,  fat,  etc.,  have  been  negative,  the  seeming  exceptions  where  such  particles 
were  found  in  the  fetal  circulation  after  injection  being  attributable  to  injury 
of  the  blood-vessels. 

The  migration  of  formed  elements,  such  as  the  pathogenic  bacteria  of 
anthrax,  typhus,  etc.  or  the  colorless  blood-corpuscles,  from  the  circulation 
of  the  mother  into  the  fetal  blood  is  a  question  about  which  there  is  much 
difference  of  opinion.  Regarding  the  blood-cells,  moreover,  the  investigations 
of  Sanger  point  to  the  improbability  of  such  migration  taking  place,  since  in 
leukemic  conditions  of  either  mother  or  child  the  blood  of  the  remaining 
organism  may  retain  its  normal  proportions.  The  experiments  of  Savory 
and  Gusserow  have  shown  that  in  animals  in  which  the  fetus  is  poisoned 
by  strychnia  the  poison  may  pass  from  the  fetal  circulation  into  that  of 
the  mother. 

Certain  substances  administered  to  the  mother  pass  into  the  liquor  amnii,  as 
in  the  case  where  iodin  is  given  (Krukenberg).  That  the  fetus  takes  no  part 
in  producing  this  effect  is  shown  by  the  fact  that  the  drug  is  found  in  the 
liquor  amnii  even  when  the  product  of  conception  is  dead  (Haidlen) ;  further, 
that  coloration  of  the  amniotic  fluid  after  the  injection  of  sodium  sulphindigo- 
tate  into  the  jugular  vein  of  the  mother  is  unattended  by  the  presence  of  the 
substance  within  either  the  kidneys  or  the  urine  of  the  fetus  (Zuntz).  The 
staining  of  the  maternal  tissues  composing  the  decidua  by  the  pigments  con- 
tained within  the  meconium  emphasizes  the  fact  that  substances  within  the 
liquor  amnii  may  in  turn  affect  the  mother. 

The  respiratory  and  metabolic  changes  within  the  fetus  are  carried  on  by 
means  of  the  oxygen  taken  up  from  the  maternal  circulation  by  the  fetal 
blood-stream  in  its  passage  through  the  placenta,  in  exchange  for  the  carbonic 
acid  and  other  products  of  tissue-change.  So  long  as  this  interchange  of  gases 
takes  place  without  interruption  in  the  placenta,  the  fetal  circulation  contains 
an  excess  of  oxygen,  since,  notwithstanding  the  small  amount  derived  from  the 
mother,  the  quantity  of  this  gas  thus  obtained  more  than  suffices  for  the  needs 
of  the  embryo,  and  induces  a  condition  of  apnea.  When  the  placental  circu- 
lation is  interrupted,  however,  as  by  compression  of  the  umbilical  cord  or  by 
premature  separation  of  the  placenta,  the  fetus  perishes  with  all  the  symptoms 
of  asphyxiation. 


PHYSIOLOGY    OF  PREGNANCY.  141 

The  direct  proof  of  the  source  of  oxygen  from  the  placenta  has  been  sup- 
plied by  the  investigations  of  Cohnstein  and  Zuntz,  who  examined  the  blood 
of  the  umbilical  vein  in  sheep,  and  found  it  richer  in  oxygen  than  that  within 
the  umbilical  arteries,  although  the  difference  between  the  arterial  and  the 
venous  blood  during  intra-uterine  life  is  much  less  marked  than  after  birth 
(Halliburton).  The  spectroscopic  analysis  of  blood  from  the  human  umbilical 
vessels  by  Zweifel  showed  the  presence  of  the  oxyhemoglobin  bands  before 
respiration  was  established. 

The  consumption  of  oxygen  by  the  fetus,  as  measured  by  the  necessities  of 
its  own  heat-production,  is  relatively  small,  since  the  maintenance  of  its  tem- 
perature is  greatly  facilitated  by  being  surrounded  by  the  liquor  amnii,  the 
warmth  of  which  is  almost  equal  to  that  of  the  fetal  blood.  The  fetus  is  still 
further  favored  by  being  spared  the  necessity  of  taking  within  its  lungs  and 
alimentary  tract  substances  which  must  be  warmed  to  its  own  temperature  at 
the  expense  of  its  own  heat.  The  presence  of  the  warmed  licjuor  amnii  also 
prevents  caloric  loss  by  either  radiation  or  evaporation. 

The  pre-natal  functions  of  the  fetus  include  limited  activity  of  the  kidneys 
and  preparatory  exercise  of  the  organs  and  glands  connected  with  the  alimentary 
tract  and  the  integument. 

The  early  excretory  apparatus  of  the  embryo  is  represented  by  the  Wolffian 
bodies  and  their  ducts  and  the  allantoic.  The  yellowish  fluid  collected  within 
the  allantoic  sac  after  its  secretion  by  the  Wolffian  bodies  cannot  be  regarded 
as  urine  in  the  strict  sense  of  the  term,  since  its  elaboration  long  precedes  the 
development  of  the  fetal  kidneys.  There  is,  however,  a  similarity  between 
the  usually  alkaline  allantoic  fluid  and  the  later  secretion  of  the  fetal  kidneys, 
the  fluid  often,  but  not  invariably,  containing  urea,  uric  acid,  the  alkaline 
chlorids,  phosphates,  and  sulphates,  as  well  as  iron,  calcium  carbonate,  and 
allantoid.  The  early  presence  of  urea  and  the  urates  renders  it  highly  prob- 
able that  the  decomposition  of  albumin  with  oxidation  begins  at  an  early  period 
of  intra-uterine  life,  the  excreted  substances  being  taken  from  the  still  imper- 
fectly differentiated  fetal  blood. 

The  question  whether  the  kidneys  under  normal  conditions  regularly  secrete 
urine  before  birth  has  received  much  attention  and  various  answers.  The 
weight  of  evidence  undoubtedly  establishes  the  exercise  of  such  function,  but 
exactly  the  period  at  which  the  secretion  of  urine  first  takes  place  is  still  unde- 
termined. After  the  establishment  of  communication  between  the  bladder  and 
the  exterior  of  the  body  by  the  formation  of  the  urethral  canal,  the  urine  is 
discharged,  during  the  later  weeks  of  gestation,  into  the  amniotic  fluid,  with  which 
it  is  in  part  swallowed  by  the  fetus.  The  coloring  matters  of  the  urine  are 
elaborated  only  in  very  limited  quantities,  as  shown  by  the  well-known  pale 
tint  of  the  fluid  voided  by  the  new-born  child. 

Digestive  Tract. — The  pre-natal  activity  of  the  glands  connected  with  the 
fetal  alimentary  tract  is  a  matter  of  much  interest  in  view  of  the  demands 
made  upon  these  organs  immediately  after  birth  to  supply  the  ferments  neces- 
sary in  the  process  of  digestion  and   assimilation.     The  inherent  difficulties 


142  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

attending  the  investigation  of  the  subject  in  the  human  fetus  have  left  our 
knowledge  on  many  points  still  far  from  satisfactory. 

The  saliva  of  the  fetus  has  received  much  attention  with  a  view  of  deter- 
mining the  presence  or  absence  of  ptyalin.  While  the  results  of  the  observa- 
tions by  various  investigators  are  contradictory,  the  positive  evidence  of  the 
presence  of  this  ferment  in  the  saliva  of  the  new-born  obtained  by  Schiffer  is 
important.  This  observer  demonstrated  the  unmistakable  presence  of  ptyalin 
in  the  salivarv  secretion  of  three  new-born  children,  thus  showing  that  the 
capability  of  converting  starch  into  sugar  exists  in  the  saliva  from  birth — a 
fact  the  more  remarkable  when  the  absence  of  the  opportunity  for  the  exercise 
of  this  power  is  recalled,  the  character  of  the  early  food  requiring  neither 
starch  nor  dextrin.  It  has  been  shown  that  the  ptyalin  is  not  elaborated  in- 
differently by  the  salivary  glands,  but  that  its  presence  is  limited  to  the  secre- 
tion and  tissue  of  the  parotid.  The  relatively  tardy  development  of  the  labial 
and  other  glands  of  the  oral  cavity  is  in  accord  with  the  observed  slight  activity 
of  the  secretory  function  of  the  mouth  of  the  fetus. 

The  gastric  secretions  of  the  new-born  have  been  found  to  contain  pepsin 
and  rennin  immediately  after  birth,  pepsin  digestion  and  the  power  of  curdling 
milk  being  established  within  a  few  hours.  The  observed  differences  in  the 
amount  of  pepsin  contained  in  specimens  of  the  mucous  membrane  of  new- 
born children  probably  depend  upon  the  variability  in  the  development  of  the 
gastric  glands,  as  pointed  out  by  Sewall. 

The  pancreatic  ferments  are  probably  represented  before  birth  by  the  pres- 
ence of  trypsin,  which  acts  especially  upon  the  proteids,  and  a  fat-splitting 
ferment  (pancreat in,  steapsin),  but  not  by  amylopsin,  which  resembles  ptyalin 
in  possessing  the  power  of  attacking  starch.  Langendorff  demonstrated  the 
presence  of  trypsin  in  the  pancreas  of  the  fetus  at  the  fifth  and  sixth  month ; 
Zweifel,  that  of  pancreatin  at  birth.  The  large  amount  of  fatty  and  albu- 
minous matters  in  the  milk  at  once  suggests  the  necessity  of  the  early  prep- 
aration of  the  digestive  ferments  required  for  the  disposition  of  these  substances. 

The  intestinal  secretions  at  birth  differ  widely  from  those  of  a  slightly  later 
period.  In  this  respect  the  observation  of  AVerber,  showing  the  relatively 
larger  number  of  Brunner's  glands  in  the  new-born  than  during  later  life,  is 
of  interest,  although  the  function  of  the  glands  within  the  fetus  is  not  obvious. 

The  liver  early  develops,  and  soon  becomes  the  most  conspicuous  organ 
connected  with  the  fetal  digestive  apparatus.  Its  large  size  suggests  an  early 
activity,  which,  in  fact,  observations  on  mammalian  embryos  confirm.  A  sub- 
stance resembling  bile  has  been  found  in  the  small  intestines  from  the  third  to 
the  fifth  month,  and  later  in  the  large  gut ;  in  this  material,  from  fetuses  of 
the  third  mouth,  Zweifel  found  the  bile-acids  and  the  biliary  pigments. 

The  meconium,  the  contents  of  the  fetal  intestinal  canal  at  birth,  presents 
a  dark,  brownish-green  or  almost  black  appearance,  and  a  soft,  viscid,  pitch- 
like consistence.  Its  source  has  been  the  subject  of  interesting  investigation, 
but  much  relating  to  its  origin  still  remains  to  be  investigated.  The  produc- 
tion of  meconium  seems  chieflv  related  to  the  formation  of  bile,  since  it  is 


PHYSIOLOGY   OF  PREGNANCY.  143 

absent  before  this  secretion  is  poured  into  the  intestinal  canal,  as  well  as  in 
cases  of  malformation  in  which  the  elaboration  of  bile  is  wanting.  The  view 
attributing  to  the  swallowed  liquor  amnii  an  active  role  in  the  formation  of 
the  meconium  is  opposed  by  the  presence  of  this  substance  in  malformed 
fetuses  in  which  the  possibility  of  entrance  of  the  amniotic  fluid  into  the  intes- 
tines was  precluded. 

Before  the  secretion  of  bile  meconium  is  not  present.  Hennig  observed 
light  yellowish-green  meconium  in  a  fetus  at  the  beginning  of  the  fourth 
month.  The  beginning  of  the  fifth  month  usually  marks  the  period  from 
which  the  meconium  is  constantly  present.  This  substance,  in  addition  to  the 
bile,  consists  of  the  unabsorbed  portions  of  the  intestinal  mucus  and  juices, 
the  secretions  of  the  glands  of  Brunner  and  of  the  pancreas,  and  of  the  swal- 
lowed amniotic  liquid,  together  with  such  remains  as  leucocytes,  intestinal  epi- 
thelium, lanugo,  epidermal  cells,  and  fat  from  the  vernix  caseosa  carried  into 
the  gut-tract  along  with  the  liquor  amnii. 

The  chemical  composition  of  meconium,  as  ascertained  by  Zweifel,  includes 
from  20  to  27  per  cent,  of  solids,  of  which  about  1  per  cent,  is  inorganic,  the 
remainder  organic ;  the  amount  of  fat  and  fat-acids  and  of  cholesterin  is  the 
same — about  .75  per  cent.  The  inorganic  constituents  include  the  phosphates 
and  sulphates  of  magnesium  and  calcium,  sodium  chlorid,  and  oxid  of  iron. 
The  principal  organic  substances  are  the  more  or  less  changed  bile-salts,  the 
unaltered  bile-pigments,  bilirubin  and  biliverdin,  and  mucin. 

3.  Multiple  Conceptions. 

The  fecundation  of  more  than  a  single  ovum,  or,  as  often  less  accuratelv 
termed,  "  multiple  pregnancy,"  is  by  no  means  an  infrequent  occurrence,  as 
the  numerous  births  of  two  or  more  children  testify.  Multiple  conceptions 
may  result  in  the  birth  of  twins,  triplets,  and,  as  great  rarities,  quadruplets ; 
a  number  of  well-authenticated  instances  of  five  children  at  one  time  are 
recorded ;  and  even  an  apparently  trustworthy  case  of  the  birth  of  six,  four 
boys  and  two  girls,  has  been  reported  by  Vassalli.  The  reputed  births  in 
excess  of  this  number  are  apocryphal. 

The  most  extensive  series  examined  with  a  view  of  determining  the  rela- 
tive frequency  of  multiple  conceptions  is  that  studied  by  G.  Veit,  which 
included  the  records  of  thirteen  million  births  in  Prussia.  According  to  these 
statistics,  twins  occur  once  in  88  births;  triplets,  once  in  7910;  aud  quad- 
ruplets, once  in  371,126.  About  a  dozen  authentic  cases  of  five  at  a  birth 
are  recorded  in  medical  literature  (Kaltenbach).  The  statistics  of  different 
countries  seemingly  point  to  considerable  variations  in  the  frequency  of  twins; 
thus,  in  Bohemia  twins  occur  once  in  about  60  births,  while  in  France  they 
appear  only  once  in  every  100.  Recent  statistics  supplied  by  the  Board  of 
Health  of  New  York  and  of  Philadelphia  place  the  frequency  of  twin  births 
in  these  cities  at  1  in  every  120  births.  In  accepting  such  conclusions,  how- 
ever, possible  errors  arising  from  differences  in  the  character  and  completeness 
of  the  statistics  compared  must  not  be  overlooked. 


144  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

Of  150,000  twin  j>reguancies  studied  by  Veit,  in  one-third  both  children 
■were  boys ;  in  slightly  less  than  one-third  both  were  girls  ;  and  in  the  remain- 
ing third  both  sexes  were  represented.  Twins  are  more  frequent  in  multiparas 
than  in  primiparse.  Individual  and  inherited  tendencies  seem  also  to  be  factors 
in  the  occurrence  of  multiple  conceptions,  since  plural  births  sometimes  render 
particular  women  or  certain  families  conspicuous. 

Twins  usually  develop  from  two  distinct  ova  derived  from  the  same  or  from 
different  Graafian  vesicles,  which  may  be  separated  widely  or  which  may  even 
be  contributed  by  different  ovaries,  as  shown  by  the  presence  and  location  of 
the  corpora  lutea.  When  derived  from  a  single  ovum,  the  existence  of  a 
double  germ  may  be  assumed,  with,  however,  the  possibility  borne  in  mind 
that  the  twins  may  have  arisen  as  the  result  of  complete  fission  of  a  single 
germ,  as  emphasized  by  Ahlfeld  in  his  investigation  of  the  production  of 
double  monsters.  Twins  originating  in  this  manner  are  termed  "  homolo- 
gous" and  are  characterized  by  remarkable  physical  and  mental  similarity. 
Of  506  cases  of  twins,  Ahlfeld  found  but  sixty-six  proceeding  from  a  single 
egg.  Twins  derived  from  a  single  ovum  are  always  of  the  same  sex ;  those 
from  two  ova  may  be  of  different  or  of  the  same  sex. 

The  arrangement  of  the  fetal  membranes  of  twins  depends  upon  the  mode 
of  their  origin.  The  decidua  vera  is  always  simple ;  the  deeidua  reflexa,  on 
the  contrary,  is  double  when  the  ova  become  attached  to  widely  separated  parts 
of  the  uterine  wall.  The  chorion,  being  primarily  derived  from  the  zona 
pellucida,  is  single  when  the  twins  originate  from  two  germs  contained  within 
a  single  ovum,  but  double  when  they  arise  from  separate  eggs.  The  amnion 
is  primarily  always  double,  since  this  membrane  is  produced  as  an  out- 
growth and  extension  of  each  embryo.  In  those  cases  where  twins  occupy  a 
common  amniotic  sac,  a  secondary  fusion  of  the  two  originally  distinct  sacs 
has  occurred  by  the  breaking  down  and  absorption  of  the  septum  which  for  a 
time  separated  them. 

The  placenta  is  at  first  double,  since  each  fetus  forms  its  own  allantois  and 
resulting  placental  area.  When  the  twins  originate  from  different  ova  the 
placenta  may  remain  permanently  distinct,  but  even  in  such  cases  fusion  of  the 
placental  ai*eas  eventually  takes  place.  The  placental  vessels  of  single-egged 
twins  almost  invariably  anastomose,  so  that  the  placentae  become  more  or  less 
completely  fused,  the  common  nutritive  area  then  consisting  of  three  parts,  an 
intermediate,  indifferent  area  being  enjoyed  in  common,  in  addition  to  the  par- 
ticular part  which  ministers  especially  to  each  fetus  (Hyrtl).  The  anastomosis 
of  the  placental  vessels  may  result  in  the  most  profound  impressions  in  those 
cases  where  marked  differences  exist  in  the  development  and  vigor  of  the  two 
fetuses,  since  the  circulation  of  the  weaker  fetus  may  be  unfavorably  influ- 
enced, even  to  the  extent  of  reversal  (Ahlfeld),  by  the  overpowering  force  of 
that  of  its  stronger  brother.  Disastrous  atrophy  and  the  production  of  an 
acardia  are  among  the  results  attributable  to  such  conditions. 

When  one  fetus  succumbs,  the  pressure  exerted  during  the  growth  of  the 
living  child  gradually  reduces  the  mass  of  the  dead  product  of  conception,  until 


PHYSIOLOGY    OF  PREGNANCY.  145 

finally  it  is  represented  by  the  greatly  flattened  and  attenuated  remains  impris- 
oned against  the  uterine  walls,  then  constituting  the  "  fetus  papyraceus  "  of  the 
teratologist.  Conspicuous,  and  sometimes  remarkable,  disparity  in  the  perfec- 
tion of  growth  and  development  may  exist  in  twins  at  birth,  the  more  favored 
fetus  sometimes  exceeding  the  smaller  threefold  in  weight,  the  difference  depend- 
ing upon  the  nutritive  advantages  enjoyed  by  the  one  at  the  expense  of  its  less 
fortunate  fellow.  In  consequence  of  this  disparity  it  sometimes,  though  very 
rarely,  happens  that  the  fully-matured  fetus  is  expelled  at  term,  while  the  still 
imperfectly  developed  fetus  is  retained  for  a  time  within  the  uterus  until  its 
development  has  progressed  farther  toward  completion,  when  it  in  turn  is  born. 
Two  remarkable  cases  in  which  double  uteri  were  present  have  been  recorded 
by  Barker  and  Generali,  where  intervals  of  forty  -three  and  thirty  days  respec- 
tively intervened  between  the  births  of  the  two  fetuses.  It  is  the  occurrence 
of  such  cases  which  is  erroneously  regarded  as  a  fact  in  support  of  the  pos- 
sibility of  superfetation. 

Triplets  may  originate,  it  is  evident,  from  a  single  ovum  or  from  two  or 
three  distinct  eggs,  a  frequent  arrangement  being  that  one  child  is  derived 
from  a  distinct  ovum  and  two  from  a  single  ovum.  Upon  the  manner  of 
their  origin  depend  the  arrangement  and  relations  of  the  placenta  and  mem- 
branes. Quadruplets  may  exist  as  double  twins,  or  they  may  result  from  a 
combination  of  a  single  birth  with  triplets. 

Plural  conceptions,  on  the  one  hand,  may  result  from  a  single  coitus, 
whereby  are  impregnated  ova  which  have  simultaneously  been  discharged  from 
the  sexual  gland,  prepared  for  the  reception  of  the  male  elements ;  on  the 
other  hand,  repeated  impregnations  may  occur  after  different,  though  closely 
following,  sexual  acts,  these  resulting  in  the  fecundation  of  different  ova  which 
have  been  liberated  at  slightly  separated  moments,  but  which  belong  to  the 
same  ovulation.  This  possibility  has  received  recognition  in  the  term  super- 
fecundation  or  superimpregnation,  by  which  is  understood  the  fecundation  of 
two  ova,  belonging  to  the  same  period,  by  different  sexual  acts.  Conspicuous 
examples  of  such  occurrences  are  afforded  by  instances  where  a  negress  gives 
birth  to  a  white  and  a  black  child. 

While  the  occurrence  of  superimpregnation  is  undisputed,  superfetation,  or 
the  possibility  of  ova  which  originate  from  different  ovulation  periods,  and  there- 
fore liberated  at  considerable  intervals,  being  impregnated  by  sexual  acts  widely 
separated,  is  not  admissible.  While  instances  of  the  delayed  birth  of  a  second 
child  are  adduced  in  support  of  the  recognition  of  the  possibility  of  superfeta- 
tion, the  obvious  physical  impossibilities  of  the  assumed  occurrence  are  unan- 
swerable objections  to  the  validity  of  such  interpretation.  When  the  rapid 
and  important  changes  in  both  the  ovum  and  its  environment  that  follow 
fecundation  are  recalled,  the  impossibility  of  spermatozoa  reaching  and  im- 
pregnating an  additional  ovum  on  the  one  hand,  and  of  the  ovum,  even 
although  fecundated,  descending  the  Fallopian  tube  to  the  uterus,  on  the 
other  hand,  is  manifest.  The  cases  cited  in  support  of  superfetation  are  all 
explicable  from  the  well-known  facts  attending  the  unequal  growth  and  devel- 
10 


146  AMERICAN    TEXT- BOOK   OF    OBSTETRICS. 

opment  of  twin  conceptions,  where  this  disparity  results  in  the  delayed  deliv- 
ery of  the  less  favored  fetus. 

Plural  births  frequently  occur  before  terra,  twins  being  born  a  few  weeks 
before  the  end  of  gestation,  quadruplets  and  quintuplets  in  the  earlier  months 
of  pregnancy. 

4.  Changes  in  the  Maternal  Organism  Induced  by  Pregnancy. 

1 .  Local  Changes. — The  presence  of  the  fecundated  ovum  inaugurates  a 
season  of  increased  nutritive  energy,  which  not  only  effects  changes  in  those 
organs  in  immediate  relations  with  the  developing  fetus,  but  also  induces 
changes  involving  the  entire  organism  of  the  mother  during  the  continuance 
of  pregnancy.  The  changes  thus  induced  in  the  general  system  being  discussed 
in  a  separate  section  (p.  154),  consideration  in  the  present  place  will  be  directed 
to  those  changes  manifested  by  the  sexual  organs  and  the  parts  intimately  con- 
nected with  the  processes  of  gestation  and  parturition. 

The  uterus,  as  may  be  expected  from  its  especial  relation  to  the  developing 
fetus,  early  manifests  the  profound  changes  which  it  undergoes ;  indeed,  the 
preparatory  alterations  affecting  its  mucous  lining  and  vascularity  preceding 
each  menstrual  epoch  must  be  regarded  as  the  beginning  of  the  cycle  of 
changes  that  ends  only  with  the  return  of  the  organ  to  its  normal  condition 
after  the  expulsion  of  the  product  of  conception  and  the  protecting  structures. 

The  hypertrophy  of  the  mucous  membrane  of  the  uterus  and  the  greatly 
increased  vascular  supply  which  take  place  coincidently  with  the  liberation  of 
the  ripe  ovum  from  the  ovary,  under  usual  conditions,  are  succeeded  by  the 
destructive  changes  giving  rise  to  the  phenomena  of  menstruation.  Should 
impregnation,  on  the  contrary,  occur,  the  hypertrophic  processes  are  continued 
with  increased  vigor,  and  result  in  the  alterations  already  described  in  con- 
nection with  the  formation  of,  the  decidua  (p.  87). 

The  most  conspicuous  consequence  of  the  changes  in  the  uterus  is  the  not- 
able increase  in  the  size  and  weight  of  this  organ.  From  the  insignificant 
dimensions  of  the  small,  rigid  virgin  uterus,  which  include  a  length  of  7  cen- 
timeters (2f  inches),  a  breadth  of  4.5  centimeters  (If-  inches),  and  a  thickness 
of  2.5  centimeters  (1  inch),  there  is  developed  a  huge  flaccid  sac  which  meas- 
ures at  the  close  of  gestation  from  37  to  38  centimeters  (15^  inches)  in  length, 
26  centimeters  (lOf  inches)  in  breadth,  and  24.4  centimeters  (9f-  inches)  in 
thickness,  with  a  circumference  at  the  level  of  the  oviducts  of  from  70  to  73 
centimeters  (29  inches). 

The  weight  of  the  virgin  uterus  is  about  40  grams  (1^  ounces);  that  of 
the  uterus  at  term,  about  1000  grams  (2  pounds),  an  increase  of  twenty-five 
times  taking  place.  The  capacity  of  the  uterus  at  the  close  of  gestation  is 
between  4000  and  5000  cubic  centimeters  (from  8  to  10  pints),  or  over  five 
hundred  times  that  of  the  virgin  organ. 

The  increase  in  the  bulk  of  the  uterus  occurring  during  the  earliest  months 
of  pregnancy  is  attributable  to  the  general  hypertrophy  affecting  its  walls,  and 
not  directly  to  the  developing  ovum,  since  only  after  the  latter  completely  fills 


PHYSIOLOGY   OF  PREGNANCY.  147 

the  uterine  cavity,  at  the  expiration  of  the  fifth  month,  is  the  augmented  size 
of  the  uterus  produced  by  the  mechanical  distention  caused  by  the  rapidly 
growing:  fetus.  The  enlargement  of  the  uterus,  moreover,  is  not  direetlv 
dependent  upon  the  presence  of  the  ovum,  but  is  due  to  actual  increase  of  tis- 
sue, as  shown  by  the  fact  that  the  hypertrophy  of  the  organ  progresses  up  to 
the  fourth  month  in  extra-uterine  pregnancies,  the  same  as  if  the  ovum  were 
present  within  the  uterine  cavity. 

The  hypertrophy  of  the  uterus  at  first  affects  equally  all  parts  of  the  viscus, 
but  later  the  fundus  and  the  body  grow  more  rapidly  than  the  cervix.  The 
changes  which  affect  the  uterine  walls  consist  of  thickening  of  the  mucous 
membrane,  increase  of  the  muscular  tissue,  augmentation  of  the  connective 
tissue,  and  enlargement  of  the  blood-vessels,  the  lymphatics,  and  the  nerves. 
As  a  result  of  these  alterations  the  walls  for  a  time  reach  a  thickness  of  1.5 
centimeters  (-|  inch);  but  this  excessive  growth  is  followed  by  a  marked 
reduction  resulting  from  the  distention  incident  to  the  later  months  of  preg- 
nancy, when  the  extended  uterine  walls  measure  but  5  millimeters  (-^  inch) 
in  thickness. 

The  increase  of  the  muscular  tunic  is  effected  not  only  by  excessive  growth 
of  the  already  existing  involuntary  muscle-fibres,  which  increase  from  ten  to 
eleven  times  in  length  and  from  three  to  five  times  in  breadth,  but  also  by  the 
formation  of  new  muscular  elements  which  likewise  soon  acquire  the  dimen- 
sions of  .5  millimeter  in  length  by  .02  millimeter  in  breadth. 

The  luminaof  the  uterine  blood-vessels  are  materially  increased,  the  arteries 
becoming  wider  and  longer — without,  however,  entirely  losing  their  tortuosity 
— and  the  veins  dilating  into  large  venous  channels,  the  swims  uterini,  which 
penetrate  between  the  muscular  fasciculi  and  which  are  particularly  well  devel- 
oped within  the  placental  area.  The  walls  of  the  venous  canals  are  intimately 
united  with  the  surrounding  and  likewise  hypertrophied  connective  tissue,  in 
consequence  of  which  arrangement  the  walls  of  these  vessels  do  not  collapse 
when  mutilated,  but  remain  more  or  less  gaping.  The  lymphatics  of  the 
mucosa  and  the  muscular  tunic  considerably  enlarge.  The  nerves  distributed 
to  the  uterus  also  share  in  the  increased  growth,  especially  the  ganglion  cervi- 
cale,  which  more  than  doubles  its  usual  size. 

The  form  of  the  uterus  undergoes  a  marked  series  of  changes  during  preg- 
nancy. During  the  first  three  months  the  pyriform  shape  is  retained  ;  subse- 
quently the  organ  becomes  more  expanded  in  its  lower  segment,  and  by  the 
fifth  month  presents  a  form  intermediate  between  the  spherical  and  the  pyri- 
form, the  longest  diameter  being  vertical,  and  the  antero-posterior  dimension 
being  greatest  just  below  the  middle  of  the  body  (Webster).  Late  in  preg- 
nancy the  pyriform  or  egg  shape  once  more  predominates,  owing  to  the  dome- 
like distention  of  the  fundus  and  the  broadening  of  the  lower  segment. 

During  the  early  months  all  parts  of  the  uterus  increase  with  equal  rapidity  ; 
after  the  fifth  month,  however,  the  cervix  participates  but  slightly  in  compari- 
son with  the  rate  of  growth  manifested  in  the  upper  part  of  the  organ..  While 
hypertrophy  of  the  cervix  is  admitted  by  all,  the  extent  to  which  this  portion 


148  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

of  the  uterus  contributes  to  the  formation  of  the  excessive  uterine  sac  present 
at  the  close  of  pregnancy  is  a  question  regarding  which  authorities  greatly 
differ.  It  may  be  stated  at  once  that  the  older  view,  that  the  cervical  canal 
gradually  unfolds  itself  into  the  uterine  cavity  as  gestation  advances,  is  no 
longer  tenable,  since  the  investigations  of  Miiller  so  clearly  showed  that  the 
cervical  canal  is  but  little  affected.  Regarding  the  question,  however,  as  to 
what  extent  the  cervix  participates  in  the  production  of  the  uterine  sac — 
whether  it  retains  its  integrity  throughout  the  entire  canal  or  contributes  a  part 
of  its  length  to  the  enlarged  muscular  bag — the  solution  is  less  readily  at  hand. 
The  differences  of  opinion  concerning  these  points  have  arisen  more  from 
differences  in  the  interpretation  of  certain  anatomical  details  than  in  their 
variation.  It  is  of  interest,  therefore,  to  note  the  structural  peculiarities  as 
repeatedly  observed  in  favorable  preparations  of  the  uterus  at  the  close  of 
pregnancy  or  at  the  beginning  of  labor.  The  classical  section  secured  by 
Braune  of  a  woman  who  died  during  the  first  stage  of  labor  (Fig.  134)  shows, 


Boundary  bet^veen  upper 
\_  and  lower  uterine  seg- 
II  ments  {Sckroedcr's  con- 
i    traction-ring). 


%%AB^;i:;:Zr'0s''Iatcd 


Fig.  134.— Section  of  the  parturient  canal  at  end  of  the  stage  of  dilatation,  from  a  woman  who  died 
during  labor  (Braune). 

in  addition  to  the  widely  dilated  os  externum,  whose  still-defined  position 
indicates  the  juncture  of  the  uterine  and  vaginal  portions  of  the  parturi- 
ent canal,  two  annular  markings  of  much  interest.  The  uppermost  of  these 
markings  is  apparent  as  a  distinct  ridge  completely  encircling  the  uterine 
sac  and  separating  the  thicker  and  more  voluminous  upper  segment  from  the 
more  dependent  lower  part.  This  projection  was  described  by  Bandl  as  the 
dilated  true  os  internum,  and  as  defining,  consequently,  the  upper  limit  of  the 
cervical  canal ;  by  Schroeder  the  same  structure  was  regarded  as  a  contraction- 
ring  which  marks  the  juncture  of  the  upper  contracted  and  the  lower  dilated 
uterine   segments.      Some    distance    lower   a    second    ridge,    slightly    marked 


PHYSIOLOGY   OF  PREGNANCY.  149 

anteriorly,  but  more  conspicuous  on  the  posterior  wall,  constitutes  Miiller's 
ring,  which  Bandl  regards  as  indicating  the  upper  border  of  that  part  of  the 
cervical  canal  which  is  unaffected  until  the  dilatation  of  labor  takes  place. 
Sehroeder,  on  the  contrary,  views  this  ridge  as  the  true  os  internum,  and  the 
zone  included  between  his  contraction-ring  above  and  the  one  in  question 
below  as  the  inferior  segment  of  the  uterus. 

From  the  foregoing  it  is  evident  that  the  significance  of  the  zone  included 
between  these  two  rings  is  the  principal  question  at  issue,  some  authorities 
regarding  it  as  a  part  of  the  true  uterine  sac,  while  others  consider  it  to  repre- 
sent the  upper  part  of  the  cervical  canal,  that  unfolds  before  the  termination 
of  gestation  and  thereby  contributes  to  the  extension  of  the  uterine  sac.  Ac- 
cording to  the  first  view,  the  cervical  canal  retains  its  integrity  throughout 
pregnancy  ;  according  to  the  second,  the  canal  participates  to  a  limited  degree 
in  the  formation  of  the  fetal  receptacle  by  dilatation  of  its  upper  portion 
toward  the  close  of  gestation.  While  both  views  claim  distinguished  names 
in  their  support,  the  weight  of  evidence  seems  to  lead  to  the  acceptance  of  the 
doctrine  attributing  a  limited  participation  of  the  cervix  in  the  formation  of 
the  uterine  sac  of  pregnancy. 

The  cervix  of  the  uterus  of  the  sexually  mature  virgin  is  about  equal  in 
length  to  the  body  of  the  organ,  and  only  in  women  who  have  borne  children 
is  the  neck  relatively  shorter  (Kussmaul).  During  the  first  three  months  of 
pregnancy  the  cervix  partakes  equally  in  the  general  hypertrophy  affecting  the 
uterus  (see  Fig.  137),  and  reaches  a  length  of  6  centimeters  (2|  inches)  or  more. 

While  it  is  only  from  the  seventh  month  that  the  os  internum  exhibits  a 
tendency  to  expand  into  the  adjacent  uterine  cavity,  the  forces  leading  to  this 
unfolding  begin  their  influence  very  much  earlier — in  fact,  as  soon  as  this 
portion  of  the  uterus  has  reached  its  maximum  hypertrophy,  or  from  about 
the  fourth  month  of  gestation.  In  addition  to  the  effects  of  the  presence  of 
the  fetus,  the  traction  exerted  by  the  muscular  bands — retractor  fibres  of 
Bayer — which  pass  from  the  outer  layers  of  the  uterus  iuto  the  round  and  the 
sacro-uterine  ligaments  is  an  important  factor  in  causing  the  gradual  unfold- 
ing of  the  cervical  canal.  The  dilated,  funnel-shaped  cavity  contributed  by 
the  cervix  for  a  long  time  retains  its  flattened  plicse  and  is  covered  by  ciliated 
columnar  epithelium ;  its  mucosa  finally  undergoes  conversion  into,  the 
decidua  by  changes  identical  with  those  taking  place  in  other  parts  of  the 
uterine  mucous  membrane.  As  a  result  of  these  changes  the  cervical  canal 
shortens,  and  at  the  close  of  gestation  measures  from  3  to  4  centimeters  (1^  to 
1^-  inches).  The  unfolding  of  the  cervical  canal  takes  place  earlier  in  priini- 
parse,  owing  to  the  greater  resistance  of  the  comparatively  rigid  muscular  tis- 
sue of  the  body  of  the  uterus,  until  now  unaffected  by  the  changes  of  preg- 
nancy. These  changes  result  in  a  general  softening  and  elasticity  of  the  body 
of  the  uterus  from  the  beginning  of  gestation,  the  cervix  retaining  its  usual 
firmness  during  the  earlier  months  almost  unimpaired.  Toward  the  close  of 
pregnancy  the  vaginal  portion  of  the  cervix  projects  less  and  less,  the  seeming 
shortening  being  probably  due,  in  part  at  least,  to  the  swelling  and  greater 


150  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

prominence  of  the  surrounding  walls  of  the  vagina  as  well  as  to  traction 
exerted  by  ascending  and  diverging  muscle-fibres. 

The  change  of  position  of  the  uterus  is  particularly  associated  with  the 
rapid  growth  of  the  body,  but  during  the  early  months  of  gestation  this 
growth  results  in  augmented  antero-posterior  and  lateral  diameters  rather  than 
in  great  increase  of  the  longitudinal  axis  of  the  organ.  In  consequence  of  this 
increase,  together  with  the  increased  anteflexion  resulting  from  the  additional 
weight  of  the  hypertrophied  tissue,  the  fundus  does  not  rise  above  the  symphy- 
sis until  the  fourth  month.  The  fundus  lies  usually  to  the  right  of  the  median 
line,  and  often  is  so  turned  on  its  long  axis  that  the  left  side  is  directed  forward. 
At  the  fifth  month  the  uterus  fills  the  hypogastrium,  from  which  time  on  the 
rise  in  the  position  of  the  fundus  is  so  regular  in  its  progression  that  under 
normal  conditions  this  detail  furnishes  valuable  assistance  in  the  estimation 
of  the  stage  of  pregnancy.  During  the  last  two  weeks  of  gestation  the  uterus 
sinks  within  the  pelvis,  the  fundus  taking  a  position  somewhat  lower  than 
before,  resting  downward  and  forward  from  7  to  8  centimeters  (2|  to  3^ 
inches)  below  the  ensiform  cartilage.  The  observations  of  Webster  led  this 
investigator  to  believe  that  the  sinking  of  the  uterus  not  infrequently  begins 
long  before  (sometimes  from  the  fifth  month)  the  last  two  weeks,  the  period 
usually  assumed. 

The  position  and  relations  of  the  full-term  uterus  alter  with  the  posture 
of  the  woman.  In  the  upright  position  the  fundus  bends  as  far  forward  as 
the  tension  of  the  distended  abdominal  walls  permits,  and  rests  against  the 
anterior  parietes.  In  the  recumbent  position  the  uterus  lies  against  the 
lumbar  part  of  the  vertebral  column,  the  fundus  approaching  the  diaphragm 
above,  with  the  intestinal  coils  in  front  and  at  the  sides.  On  assuming  the 
lateral  posture  the  large,  flaccid  uterine  sac  becomes  dependent  on  the  corre- 
sponding side. 

The  relations  of  the  -peritoneum,  and  the  uterus  become  disturbed  in  conse- 
quence of  the  altered  position  of  the  latter  and  the  excessive  tension  caused  by 
its  enormous  proportions.  The  layers  of  the  broad  ligaments  become  gradu- 
ally separated  and  the  entire  structures  shortened,  in  consequence  of  which  the 
Fallopian  tubes  and  the  ovaries  are  drawn  toward  the  uterus,  against  which 
they  lie  at  the  close  of  gestation. 

The  changes  in  the  disposition  of  the  pelvic  peritoneum  during  pregnancy 
have  been  by  no  means  definitely  determined,  and  opinions  differ  as  to  the 
forces  leading  to  such  alterations  as  well  as  to  the  extent  of  displacement. 
Regarding  the  lateral  arrangement,  it  is  evident  that  the  increase  in  the  trans- 
verse and  vertical  diameters  of  the  uterus  must  result  in  the  elevation  of  the 
peritoneum  on  each  side  of  the  pelvis  to  a  considerable  degree,  as  conclusively 
demonstrated  by  the  observations  of  Barbour  and  Polk.  The  arrangement  in 
front  and  behind,  however,  is  not  so  clear,  and  the  statements  of  authorities 
are  conflicting.  Polk  maintains  that  the  lowest  situation  of  the  peritoneum 
in  front  and  behind  the  uterus,  with  the  exception  of  Douglas's  pouch,  in  the 
non-pregnant  condition   is   indicated   by  a  line  passing  from  the  centre  of  the 


PHYSIOLOGY   OF  PREGNANCY.  151 

symphysis  to  the  juncture  of  the  third  and  fourth  sacral  vertebrae.  At  the 
termination  of  pregnancy,  but  before  the  usual  sinking  of  the  uterus  within 
the  pelvis  has  occurred,  the  lowest  limit  of  the  peritoneum,  according  to  the  same 
observer,  has  ascended  and  is  now  marked  by  a  line  passing  from  the  centre 
of  the  symphysis  to  the  sacral  promontory. 

These  conclusions  are  not  confirmed  by  examinations  of  frozen  sections 
made  by  Webster,  since  this  author  finds  the  inferior  limit  of  the  peritoneal 
pouches  during  pregnancy  as  low  as  in  nullipara?.  The  changes  in  the  ante- 
rior relations  of  the  peritoneum  of  the  vesico-uterine  fossa,  whereby  the  peri- 
toneum becomes  stripped  from  the  bladder,  are  usually  regarded  as  due  to  the 
elevation  of  the  uterus  and  to  the  consequent  mechanical  effect,  which  together 
are  also  supposed  to  exert  an  influence  by  which  the  floor  of  the  pouch  of 
Douglas  is  raised.  Webster  attributes  the  stripping  of  the  peritoneum  from 
the  bladder,  on  the  contrary,  to  the  drag  caused  by  the  gradual  sinking  of  the 
pelvic  floor,  since  the  delicate  subserous  tissue  gives  way7  under  the  traction, 
and  the  peritoneum  consequently  does  not  follow  the  posterior  wall  of  the 
bladder  in  its  descent.  The  extent  to  which  the  stripping  of  the  serous  cover- 
ing takes  place  depends  largely  upon  the  capacity  of  the  peritoneal  folds  exist- 
ing in  the  non-pregnant  condition,  as  when  these  are  ample  less  displacement 
follows  than  when  the  traction  cannot  be  met  with  supplementary  tissue. 
According  to  Webster,  the  central  portion  of  the  pouch  of  Douglas  at  no  time 
during  pregnancy  becomes  elevated  ;  this  author  further  points  out  that  the 
sinking  of  the  uterus  may  be  progressive  from  the  middle  of  pregnancy, 
resulting  in  the  marked  downward  displacement  of  the  organ  sometimes 
observed  before  the  end  of  gestation. 

The  vagina  also  exhibits  changes  resulting  from  the  exaggerated  nutrition 
of  pregnancy.  These  changes  include  greatly;  increased  vascularity,  thickening 
and  softening  of  its  mucous  membrane,  whose  folds  become  less  rigid  and  con- 
spicuous, and  hypertrophy  of  the  muscular  tunic  with  great  dilatation  of  the 
blood-vessels.  In  consequence  of  the  large  quantity  of  blood  contained  within 
the  less  compact  tissues,  the  vaginal  surface  presents  a  bluish  tint  in  contrast 
with  the  bright  red  of  its  usual  condition.  This  change  of  color  is  regarded 
by  some  as  a  valuable  objective  sign  of  pregnancy. 

The  external  genitals  likewise  participate  in  the  increased  hyperemia  of  the 
generative  tract,  the  unusual  development  of  the  blood-vessels  and  the  lymph- 
atics inducing  a  condition  characterized  by  softening  and  greater  infiltration  of 
the  tissues,  hence  the  vulva  appears  particularly  prominent.  The  excessive 
vascularity  of  the  parts  finds  expression  in  the  dusky  hue  and  the  unusual 
activity  of  the  sebaceous  follicles  and  the  sweat-glands  of  the  labia. 

The  articulations  of  the  pelvis  exhibit  to  a  limited  degree  changes  due  to 
pregnancy.  These  changes  are  manifested  by  an  unusual  softening  and  vascu- 
larity of  the  interarticular  cartilage,  particularly  that  of  the  symphysis,  in 
consequence  of  which  there  takes  place  a  certain  amount  of  loosening,  attended 
in  some  cases  with  slight  movement.  Whatever  temporary  increase  in  the  pel- 
vic boundary  may  thus  be  secured,  the  gain  at  best  is  probably  very  insignificant. 


152 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


Other  changes  affecting  the  pelvic  floor  and  the  parts  closely  connected 
therewith,  such  as  the  base  of  the  bladder  and  the  urethral  orifice,  result  from 
the  downward  displacement  of  the  structures  closing  in  the  outlet  of  the  pelvis. 
The  pelvic-floor  projection  is  progressively  increased  from  2.5  centimeters  (1 
inch)  in  the  nullipara  to  9.5  centimeters  (3f  inches)  at  the  end  of  pregnancy ; 
the  skin-distance  from  the  symphysis  to  the  coccyx  is  almost  doubled. 

The  following  table,  compiled  by  Webster,  based  on  the  observations 
of  himself  and  of  other  observers,  displays  some  of  the  more  important 
variations  induced  by  pregnancy  within  the  parts  in  relation  to  the  pelvis : 


Pelvic-floor  projection 

Skin-distance  from  coccyx  to  symphysis 

Distance  of  urethral  orifice  below  brim     

Distance  of  urethral  orifice  below  symphysis 

Distance  of  junction  of  bladder  and  urethra  below  brim 
Thickness  of  tissue  between  pubes  and  vagina  .   .... 

Depth  of  utcro-vesical  pouch  below  brim 

Distance  of  os  externum  below  brim  posteriorly  .... 
Distance  of  os  externum  below  brim  anteriorly  .... 
Distance  of  os  internum  below  brim  posteriorly  .... 
Distance  of  os  internum  below  brim  anteriorly    .... 


Nul- 

Fifth 

Eighth 

lipara. 

Month. 

Month. 

Cm. 

Cm. 

Cm. 

4.1 

5.0 

13.5 

14.0 

16.5 

6.1 

6.7 

6.7 

0.6 

3.2 

6.4 

7.6 

6.3 

1.6 

2.8 

3.5 

6.7 

6.3 

11.1 

8.7 

6.3 

11.1 

8.7 

5.7 

7.9 

7.0 

5.7 

7.9 

7.0 

The  abdominal  walls  manifest  the  enormous  distention  to  which  they  are 
subjected  by  the  formation  of  more  or  less  conspicuous  lines — the  strioz  gravi- 
darum— which  are  found  in  over  90  per  cent,  of  pregnant  women.  These 
lines  appear  as  reddish  or  bluish,  sometimes  lighter,  streaks,  which  are  most 
numerous  and  well  marked  during  the  last  months  of  pregnancy  over  the 
lower  part  of  the  abdomen,  particularly  at  the  sides.  They  extend  as  curved 
or  sinuous  lines,  and  they  persist  for  some  considerable  time  after  the  termina- 
tion of  o-estation,  gradually  becoming  whiter  and  more  cicatricial  in  appearance. 
These  strife  are  due  to  displacements  and  partial  rupture  and  atrophy  of  the 
connective  tissue  of  the  deep  layer  of  the  greatly  distended  cutis.  They  are 
not  peculiar  to  pregnancy,  but  may  appear  even  in  men  whenever  the  skin  is 
subjected  to  unusual  stretching,  as  from  tumors,  ascites,  and  other  causes; 
furthermore,  they  are  not  limited  to  the  abdomen,  but  in  pregnancy  are  seen 
on  the  nates,  the  thighs,  and  the  breasts. 

The  linea  alba  also  not  infrequently  becomes  broader,  and  in  multipara?  the 
recti  muscles  are  sometimes  so  widely  separated  that  the  mass  of  the  uterus 
appears  between  as  a  median  projection. 

The  umbilicus  is  affected  by  the  increasing  bulk  of  the  abdominal  contents, 
and  by  the  fifth  month  begins  to  exhibit  a  diminution  in  its  depths;  by  the 
seventh  month  its  depression  has  become  obliterated,  and  during  the  remaining 
weeks  it  becomes  gradually  everted  until  the  umbilicus  forms  a  rounded 
elevation. 

The  mammary  glands,  coincidently  with  the  changes  affecting  the  genera- 
tive organs,  undergo  important  alterations  during  the  preparation  for  their 
assumption  of  the  stage  of  functional  activity.     These  changes  early  induce 


PHYSIOLOGY    OF  PREGNANCY, 


153 


greater  general  volume  of  the  breasts,  depending  upon  an  increase  both  of 
the  interlobular  connective  tissue  and  fat  and  of  the  true  secreting  tissue  of 
the  glands.  The  enlargement  of  the  breasts  begins  as  early  as  the  second 
month,  but  it  does  not  become  conspicuous  until  toward  the  middle  of  preg- 


Fig.  135. — Virgin  nipple  and  areola:  1,  nipple;  2,  areola 

of  nipple. 


3,  tubercles  of  Morgagni ;  4,  crevice  at  base 


nancy.  On  touch  the  periphery  of  the  organ  presents  uneven  and  knotty 
masses  consisting  of  the  enlarged  acini  and  lobules  of  the  rapid-growing 
glandular  tissue  imbedded  within  the  areolar  and  adipose  tissue.  The  ulti- 
mate compartments  of  the  secreting  structure  become  earliest  enlarged  ;  couse- 


Fig.  136. — Nipple  and  breast  of  pregnancy :  1,  nipple  with  openings  of  milk-ducts  :  2,  primary  areola ; 
3,  glands  of  Montgomery  ;  5,  secondary  areola ;  6,  venous  circle  of  Haller. 

quently  the  increase  is  first  noticeable  at  the  periphery,  afterward  extending 
along  the  course  of  the  larger  ducts  toward  the  centre  of  the  organ.  The  dis- 
tention of  the  skin  due  to  the  augmented  volume  of  the  glands  is  especially 
marked  over  the  periphery,  in  which  location  reddish,  bluish,  or  whitish  strise, 


154  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

similar  to  those  seen  upon  the  distended  abdominal  walls,  appear  as  manifes- 
tations of  the  unusual  tension  of  the  integument.  The  veins  are  also  enlarged, 
and  show  through  the  tightly  drawn  skin  as  a  network  of  blue  lines. 

The  nipple  shares  in  the  general  hypertrophy  of  the  organ,  becoming 
enlarged,  more  readily  erectile,  and  sensitive.  The  surrounding  rosy  areola 
of  the  virgin  (Fig.  135)  is  gradually  replaced  by  a  more  deeply  colored  area,  the 
tint  of  which  by  the  middle  of  pregnancy  varies  from  the  slight  brownish  discol- 
oration seen  in  women  of  light  complexion  to  the  dark  brown  or  almost  black 
color  seen  in  brunettes  (see  PI.  17).  The  areola  by  the  eighth  or  the  ninth 
week  becomes  softer  and  more  elevated  than  usual,  and  its  sebaceous  glands, 
from  one  to  two  dozen  in  number,  greatly  enlarge,  those  at  the  periphery 
becoming  particularly  conspicuous.  These  modified  sebaceous  follicles  consti- 
tute the  glands  of  Montgomery  (Fig.  136).  The  mammary  areola  varies  from 
2.5  to  4  centimeters  (1  to  1^  inches)  in  diameter,  although  these  dimensions 
may  greatly  be  exceeded.  In  the  fifth  or  the  sixth  month  of  pregnancy  an 
additional  irregularly  pigmented  area,  the  so-called  "  secondary  areola,"  some- 
times appears  (see  PI.  17). 

After  the  third  month  of  gestation  the  breasts  contain  a  thin  fluid,  the 
colostrum,  which  may  be  pressed  out  of  the  newly  formed  glandular  tissue. 
This  fluid  consists  of  a  thin  albuminous  medium  containing  numbers  of  fat- 
drops,  displaced  epithelial  cells,  and  characteristic  aggregations  known  as 
"  colostrum-corpuscles." 

2.  General  Changes. — Pregnancy,  while  a  purely  physiological  con- 
dition, creates  great  and  important  changes  in  the  maternal  organism. 
These  changes  pertain  to  the  different  systems  and  organs  of  the  body ;  to 
some  more  than  to  others.  The  general  changes  in  the  maternal  organism 
depend  to  a  great  extent  on  the  alterations  in  the  blood  and  in  the  functional 
modifications  of  the  nervous  system.  The  pregnant  woman  has  to  provide 
nutriment,  to  breathe,  to  maintain  blood-circulation,  to  secrete  and  to  excrete 
for  two  individuals — herself  and  her  fetus.  All  this  means  that  extensive 
changes  in  the  general  system  must  occur.  If  these  changes  are  carried  to  a 
reasonable  extent,  health  is  maintained  and  the  system  becomes  fortified,  as 
it  were,  for  the  coming  parturition ;  but  when  these  changes  are  developed  to 
excess,  disorders  complicating  the  pregnancy  are  produced. 

Changes  in  the  Circulatory  System. — Formerly  it  was  supposed  that  preg- 
nancy was  accompanied  by  blood-changes  like  unto  plethora,  and  it  was  almost 
universally  inferred  that  the  attending  symptoms — the  headache,  the  ring- 
ing in  the  ears,  the  flushed  face,  the  cardiac  palpitation,  and  the  dyspnea — 
were  the  results  of  these  alterations.  Consequently  it  was  a  very  common 
practice  with  phvsicians  many  years  ago  to  bleed  pregnant  women  from  one 
to  many  times  at  intervals  during  the  latter  months  of  pregnancy.  Enormous 
quantities  of  blood  were  thus  extracted  by  venesection.  A  wonderful  revolu- 
tion has  taken  place  in  the  treatment  of  pregnant  women  during  the  past 
twenty-five  years,  owing  to  more  rational  ideas  of  the  real  condition  of  the 
circulatory  fluid. 


PHYSIOLOGY   OF  PREGNANCY.  155 

In  pregnancy  the  composition  of  the  blood,  which  is  increased  in  quantity, 
is  profoundly  altered,  but  not  equally  in  all  its  constituent  parts,  as  many 
careful  analyses  prove.  The  quantity  of  blood  present  before  pregnancy 
would  be  inadequate  to  meet  the  condition  of  pregnancy.  Thus,  the  blood 
is  increased  in  its  watery  elements  and  white  corpuscles,  but  is  made  deficient 
in  the  element  of  albumin,  is  increased  materially  in  the  amount  of  fibrin, 
and  is  diminished  relatively  in  the  proportion  of  red  corpuscles — conditions 
of  anemia,  hydremia,  and  hyperinosis.  This  hyperinosis  is  also  augmented 
after  parturition,  because  at  this  time  large  quantities  of  effete  materials  are 
thrown  into  the  circulation. 

Instead  of  a  blood-change  called  "plethora"  being  present,  it  should  be 
recognized  as  one  of  anemia  and  hydremia  orof  chlorosis.  If  called  "plethora/' 
it  should  be  named  serous  plethora.  Individual  variations  in  the  quantity 
and  quality  of  the  blood  are  dependent  on  many  conditions  of  hygiene  and 
diet ;  poor  hygiene  reduces  the  blood  to  marked  chlorosis  and  hydremia.  The 
surrender  of  the  maternal  nutritive  material  to  a  growing  fetus  and  a  devel- 
oping uterus,  to  pelvic  tissue,  and  to  glands  means  a  great  tissue-drain  on  the 
maternal  circulatory  fluid.  As  these  changes  in  blood-quality  are  most  marked 
at  the  close  of  utero-gestation,  the  attending  phenomena  must  be  those  that 
are  most  strongly  shown.  Certain  thrombotic  affections  observed  in  preg- 
nancy and  after  delivery  are  thus  explainable.  In  place  of  the  blood-supply 
at  this  time  being  improved  by  bloodletting,  it  must  clearly  be  evident  that 
venesection  is  strongly  contra-indicated,  for  it  tends  further  to  aggravate  the 
abnormal  alteration.  To  Cazeaux  are  we  indebted  for  much  of  our  present 
knowledge  of  the  blood-changes  of  pregnancy. 

Certain  viscera  of  the  circulatory  apparatus  are  also  much  modified  in  size 
and  in  function.  The  heart  becomes  physiologically  hypertrophied — a  fact 
known  for  many  years  and  determined  by  numerous  observations.  This  hy- 
pertrophy  is  a  wise  provision  of  nature  to  meet  the  increasing  exigencies  of 
the  blood-supply  in  the  advancing  months  of  pregnancy.  Hypertrophy  of  the 
heart  is  constantly  present  to  a  considerable  degree,  the  whole  weight  of  this 
organ  being  one-fifth  more  in  the  pregnant  than  in  the  non-pregnant  state. 
The  left  ventricle,  the  propelling  part  of  this  organ,  is  alone  affected.  This 
physiological  hypertrophy  remains  during  the  period  of  lactation  in  those  who 
suckle  their  children,  otherwise  the  organ  quickly  diminishes  in  size;  hence 
in  women  who  have  borne  many  children  the  heart  may  remain  permanently 
large.  Incident  to  the  total  blood-supply  in  pregnant  women  the  maintenance 
of  the  circulation  demands  either  greater  frequency  in  the  heart-contractions 
or  an  increase  in  the  entire  quantity  of  blood  entering  the  left  ventricle.  The 
multiplied  vascular  elements  of  the  pelvic  organs  also  increase  the  labor 
thrown  on  the  heart.  The  pulse  does  not  undergo  the  usual  acceleration 
when  she  changes  from  a  horizontal  to  an  erect  posture. 

Disturbances  of  the  circulatory  organs  are  very  often  seen.  The  heart 
of  the  pregnant  woman  shares  in  the  nervous  irritability  of  the  whole  organ- 
ism— she  is  then  more  susceptible  to  so-called  "  cardiac  nerve-storms."    Thus, 


156  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

palpitation,  while  purely  sympathetic  in  the  earlier  months  of  gestation, 
later  comes  on  from  the  encroachment  of  the  enlarged  and  enlarging  uterus 
pushing  up  the  diaphragm  and  embarrassing  the  heart's  action.  The 
blood-changes  of  anemia  and  of  hydremia  may  be  so  great  that  edema 
may  be  observed  in  the  feet  and  may  extend  upward  to  the  thighs  and 
the  labia  majora. 

Other  organs  are  likewise  increased  in  size.  The  liver  and  the  spleen  are 
enlarged.  The  spleen  normally  increases  in  size,  owing  to  an  important  rela- 
tion to  the  quantitative  change  in  the  circulatory  fluid.  A  fatty  degeneration 
shows  itself  in  both  the  liver  and  the  spleen  in  women  who  have  suddenly 
died  after  labor.  Numerous  small  yellow  spots  are  seen  scattered  through  the 
liver — fatty  deposits  in  the  hepatic  cells.  The  thyroid  gland  is  increased  in 
size.  In  women  in  whom  there  is  a  predisposition  to  this  enlargement,  preg- 
nancy may  further  stimulate  the  growth  and  bring  about  permanent  structural 
changes.  The  enlargement  of  this  organ  is  thought  to  sustain  some  relation 
to  changes  in  the  heart  and  the  blood-glandular  system. 

Changes  in  Respiration. — Pressure  of  the  enlarging  uterus,  through 
mechanical  action,  causes  changes  in  the  respiratory  organs.  An  upward 
movement  of  the  diaphragm  lessens  the  longitudinal  dimensions  of  the  thorax. 
Some  embarrassment  of  the  respiration  follows  this  decrease,  notwithstanding 
that  there  is  some  increase  in  the  breadth  of  the  lower  thorax.  In  the  last 
two  weeks  of  utero-gestation,  owing  to  the  limited  shortening  of  the  cervix 
uteri  and  to  the  settling  down  of  the  fetus  in  utero,  respiration  and  circulation 
become  easier.  The  examination  of  expired  air  shows  some  increased  activ- 
ity of  the  lungs,  in  excretion  the  lungs  sharing  the  work  of  other  excretory 
organs,  in  disposing  of  the  extra  effete  products  from  mother  and  fetus. 

As  more  blood  must  naturally  be  provided  to  nourish  the  woman  and  her 
child  during  pregnancy,  this  extra  blood  must  not  only  be  properly  circu- 
lated, but  must  also  be  duly  purified.  The  elimination  of  carbonic-acid  gas 
by  respiration  is  therefore  increased  in  pregnancy. 

The  respiratory  organs  may  be  deranged  by  cough  and  dyspnea  originating 
from  nervous  sympathy  in  the  earlier  months  of  pregnancy.  In  the  later 
months  of  gestation  the  derangement  is  from  encroachment  of  the  gravid 
uterus,  interfering  with  normal  respiration.  These  phenomena  are  mostly 
observed  when  there  is  twiu  pregnancy  or  dropsy  of  the  amnion. 

Changes  in  the  Digestive  System  and  in  Nutrition. — The  pregnant  woman 
provides  the  nutritive  pabulum  by  which  the  growing  organs  are  sustained 
and  by  which  the  fetus  and  its  appendages  are  built  up.  She  must  therefore 
digest  more  food,  form  more  blood,  and  increase  the  activity  of  the  secretory 
and  excretory  organs.  Very  few  women  escape  such  troubles  of  digestion  as 
nausea  and  vomiting.  In  the  earlier  months  the  appetite  is,  as  a  rule,  capri- 
cious. Further  along  the  appetite  and  the  digestion  increase  in  activity, 
thereby  assisting  in  improving  the  general  nutrition. 

An  increase  of  weight  takes  place  in  normal  cases,  irrespective  of  the  grow- 
ing uterus  and  the  ovum.     The  fetus  itself  weighs  about  seven  pounds,  the 


PHYSIOLOGY    OF  PREGNANCY.  157 

liquor  amnii  one  pound,  the  placenta  one  pound,  and  the  uterus  about  two 
pounds.  The  average  gain  of  the  woman  amounts  to  from  ten  to  fifteen 
pounds  in  the  whole  nine  months,  being  greatest  in  the  last  two  months. 
This  increase  is  usually  not  far  from  one-thirteenth  of  the  whole  body- 
weight,  and  it  is  progressive  from  the  beginning  to  the  end  of  pregnancy, 
notwithstanding  the  nausea  and   vomiting. 

The  adipose  tissue  increases  most  in  bulk,  especially  in  the  latter  half  of 
gestation.  These  deposits  are  most  noticeable  iu  the  mammary  glands,  in 
the  abdominal  parietes,  iu  the  hips,  and  in  the  omentum.  The  whole  figure 
becomes  fuller  and  rounder.  All  this  increase  is  but  so  much  stored-up  poten- 
tial energy,  to  be  utilized  after  delivery,  when  this  energy,  by  the  metabolism 
of  the  body,  assists  the  mammary  function. 

Rokitansky  has  spoken  of  the  lamellae  of  osseous  material  on  the  inner  sur- 
face of  the  skull  and  the  frontal  and  parietal  bones  external  to  the  dura  mater, 
called  "puerperal  osteophytes."  These  lamellae,  which  are  irregular  in  shape, 
consist  of  calcium  carbonate,  traces  of  phosphates,  and  organic  matter.  They 
are  not  peculiar  to  pregnaucy.  Robert  Barnes  thought  they  sustained  some 
relation  to  the  calcareous  changes  found  in  the  placenta  and  to  the  forthcoming 
milk.  The  temperature  of  the  body  in  pregnancy  is  not  materially  changed, 
although,  according  to  some  authorities,  it  is  slightly  lower  in  the  morning 
than  during  the  day. 

Changes  in  the  Skin,  the  Gait,  and  the  Osseous  Elements. — The  functional 
activity  of  the  sebaceous  glands,  the  sweat-glands,  and  the  hair-follicles  of 
the  skin  is  increased  by  pregnancy.  It  has  been  said  by  Robert  Barnes  that 
the  growth  of  the  hair  is  invigorated  during  pregnancy  when  prior  to  ges- 
tation the  hair  had  been  falliug  out. 

Pigmentations  are  quite  generally  observed  iu  spots  over  the  body,  the 
linese  albicantes  beiug  most  noticeable.  They  are  also  seen  about  the  abdomen, 
the  navel,  and  on  the  face.  Around  the  nipples  these  deposits  may  be  seen  in 
the  form  of  areolae,  primary  and  secondary  (see  PI.  17).  These  pigmentations 
vary  much  iu  extent  and  in  intensitv  in  different  subjects,  being  more  marked 
in  brunettes  than  in  blondes.  Seldom  do  these  deposits  completely  disappear, 
but  they  are  always  less  after  parturition.  It  is  not  unlikely  that  they  are 
the  result  of  a  temporary  hypertrophy  of  the  suprarenal  capsules. 

There  is  also  a  change  in  the  gait  of  a  pregnant  woman.  To  preserve  the 
centre  of  gravity  of  the  body  the  head  and  shoulders  must  be  thrown  back- 
ward. This  action  produces  a  chauge  in  the  gait  most  noticeable  in  women  of 
low  stature. 

Owing  to  the  drain  on  the  osseous  elements  of  the  blood  during  pregnancy 
by  the  growing  fetus,  there  is  always  a  considerable  delay  in  the  union  of 
fractured  bones. 

Changes  in  the  Urine. — Owing  to  the  hydremic  condition  existing  during 
pregnancy,  the  urine  becomes  more  abundant  and  of  a  lower  specific  gravity. 
It  is  thought  that  the  kidneys  become  enlarged,  which  is  probably  the  case. 
This  change  in  the  size  of  the  kiduevs  has  somewhat  to  do  with  the  increased 


158  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

quantity  of  urine,  but  more  probably  the  more  active  function  is  attributable 
to  the  increased  blood-supply  and  to  the  increased  arterial  tension.  The 
urine  may  be  diminished  in  quantity,  be  high  colored,  have  a  high  specific 
gravity,  as  a  result  of  dietetic  errors,  or  some  inactivity  of  the  bowels  or 
skin.  If  not  indicative  of  renal  disease,  it  is  transient  and  unattended  by 
symptoms. 

The  quantity  of  urea  excreted  is  normal  usually. 

There  are  also  qualitative  changes  in  the  urine.  The  chlorids  have  been 
found  increased,  while  the  phosphates  and  sulphates  are  decreased,  due  to  their 
use  in  the  growth  of  the  fetus.  The  kiestein  pellicle  found  upon  the  urine 
of  pregnant  women  several  hours  after  its  excretion  has  no  necessary  relation 
to  pregnancy,  because  it  is  found  on  the  urine  of  virgins  and  on  that  of  men. 

The  glucose  found  in  the  urine  of  many  pregnant  women  in  variable 
quantities  has  been  referred  to  a  pathological  increase  in  the  glycogenic  func- 
tion of  the  liver.  Sugar  is  present  in  the  urine  of  almost  every  woman  at 
some  period  of  lactation  being  influenced  much  by  the  character  of  the  diet. 
Its  presence  depends  on  the  quantity  and  quality  of  the  milk,  diminishing  as 
the  lacteal  secretion  is  suppressed.  Glycosuria  of  pregnancy  ranks  next  to 
albuminuria  in  clinical  importance.  It  may  develop  in  every  pregnancy,  to 
disappear  after  parturition. 

Traces,  more  or  less  in  quantity,  of  albumin  are  found  in  the  urine. 
Authorities  differ  as  to  the  frequency  of  albuminuria  in  pregnancy.  Schroeder 
savs  that  the  urine  of  all  pregnant  women  will  contain  albumin  in  from  3  to 
5  per  cent. ;  other  authors  have  contended  for  a  much  larger  percentage 
(from  20  to  30).  Uncpiestionably,  albumin  is  found  in  the  urine  of  a  very 
large  number  of  pregnant  women.  No  regard  being  paid  to  the  number  of 
pregnancies,  nor  to  the  previous  condition  of  the  kidneys,  the  presence  at 
some  time  of  a  trace  of  albumin  will  be  found  in  a  very  large  number 
of  cases.  The  writer,  who  instituted  these  examinations  in  a  large  clinical 
experience  in  hospitals,  has  found  the  frequency  to  be  at  least  30  per  cent.,  not 
constantly,  but  present  in  some  variable  quantity  at  some  time  in  gestation. 
This  frequency  must  be  inquired  into  with  reference  to  its  etiology.  In  the 
first  place,  quite  a  number  of  pregnant  women  have  a  physiological  albumi- 
nuria. The  trace  of  albumin  is  then  small  and  of  short  duration  ;  there  are 
no  tube-casts,  and  no  attending  morbid  symptoms.  Every  authority  must  coin- 
cide with  Mdricke,  that  albuminuria  is  relatively  commoner  during  labor  than 
during  pregnancy.  A  prolonged  labor  is  oftener  thus  accompanied  than  is  a 
short  and  easy  labor.  Albuminuria  is  often  confined  exclusively  to  the  period 
of  labor.  The  occurrence  of  albuminuria  during  labor  is  explained  by  the 
theory  that  the  reflex  vaso-motor  spasm  of  the  renal  arteries,  resulting  from 
uterine  contractions,  causes  renal  anemia.  This  theory  has  the  support  of 
Tyler  Smith,  Spiegelberg,  and  others. 

Renal  albuminuria  may  appear  early  in  pregnancy,  before  there  is  any 
possible  renal  venous  stagnation  from  pressure,  being  the  result  purely  of 
reflex  irritation.     "Whv  should  not  this  irritation  at  times  be  transferred  from 


PHYSIOLOGY   OF  PREGNANCY.  159 

the  uterus  to  the  kidneys  as  well  as  to  the  stomach  ?  Such  an  explanation  must 
hold  good,  if  albuminuria  is  present  early  in  pregnancy,  the  urine  having  been 
normal  before  that  time.  There  is  an  intimate  connection  between  the  nervous 
ganglia  of  the  pelvis  and  the  nerve-filaments  of  the  kidneys. 

The  hydremic  state  of  the  blood  incident  to  pregnancy  is  at  times  a  cause 
of  albuminuria.  An  increased  arterial  tension  which  exists  in  pregnancy  may 
be  productive  of  albuminuria.  The  urine  of  a  pregnant  woman  may  be 
albuminous  from  causes  not  nephritic,  yet  morbid.  Thus,  it  may  be  albumin- 
ous from  blood,  from  mucus,  or  from  pus  in  the  urine,  each  of  which  may  be 
cystic,  vaginal,  or  uterine  in  origin. 

The  prevalence  of  albuminuria  during  pregnancy  may  be  classified  as  fol- 
lows: (a)  Cases  in  which  it  was  present  when  conception  took  place,  a  chronic 
Bright's  disease  of  some  type,  with  albuminuria,  having  existed  before  preg- 
nancy ;  (6)  Cases  in  which  albuminuria  from  sub-acute  or  chronic  Bright's 
disease,  the  result  of  scarlet  fever,  etc.,  had  existed  years  before,  and  from 
which  disease  a  recovery  seemingly  had  taken  place :  at  least  there  was  no 
trace  of  albumin  in  the  urine  at  the  time  of  conception  ;  (c)  Cases  in  which  the 
existing  pregnancy  or  parturition  was  attended  by  an  albuminuria,  it  having 
never  existed  before. 

In  the  first  two  divisions  of  the  above  classification  pregnancy  aggravated 
or  caused  a  return  of  the  albumin.  In  the  last  division  albuminuria  started 
during,  and  had  been  clearly  attributable  to,  the  condition  of  pregnancy. 

Excepting,  then,  the  cases  in  which  the  albuminuria  has  been  due  to 
physiological  or  pathological  causes,  not  nephritic,  and  not  attributable  to 
pregnancy,  the  author  is  disposed  to  think  that  the  estimate  made  by  Schroeder 
(3-5  per  cent.)  is  not  wide  of  the  actual  facts. 

The  oldest  theory  is  that  albuminuria  and  kidney  disease  during  pregnancy 
are  due  to  mechanical  pressure  of  the  gravid  uterus  od  the  renal  blood-ves- 
sels, especially  on  the  veins.  All  admit  that  this  mechanical  pressure  pre- 
disposes to,  if  it  does  not  excite,  the  disease.  This  doctrine  has  been  ably 
advocated  by  Simpson,  Carl  Brown,  and  Cazeaux.  It  is  not  so  much  the 
renal  pressure  alone  as  it  is  the  intra-abdominal  pressure  that  so  acts.  Support 
of  this  theory  is  obtained  from  the  following  facts : 

Albuminuria  is  more  common  in  the  latter  half  than  in  the  first  half  of 
pregnancy.  More  cases  exist  among  primiparse,  in  whom  there  is  great  ab- 
dominal pressure  from  the  rigid,  unyielding  abdominal  walls.  Albuminuria  is 
greater  in  twin  pregnancy  ;  it  is  also  common  when  there  is  a\  severe  pressure 
from  large  uterine  fibroids  or  from  ovariau  cysts.  Tight  lacing  and  heavy 
skirts  aggravate  the  disease.  It  is  less  frequent  during  gestation  than  during 
labor,  when  pressure  is  greatest ;  it  diminishes  after  labor  or  after  the  removal 
of  the  abdominal  tumors.  Any  cause  that  brings  about  renal  venous  stasis  pre- 
disposes to  and  excites  nephritis.  For  instance,  valvular  defects  and  pul- 
monary emphysema,  as  well  as  pregnancy,  may  develop  true  parenchymatous 
inflammation  of  the  kidneys. 

No  one  of  all  the  above  theories  or  facts  constitutes  a  sufficient  explanation 
for  all  cases.     Each  fact  or  theorv  may  answer  for  some  cases;  two  or  more 


160  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

combined  afford  a  better  solution  for  most.  All  can  recognize  the  influence 
of  intra-abdominal  tension  with  pressure  on  the  vena  cava  and  its  branches, 
especially  in  primiparous  women.  The  sinking  of  the  fetal  head  into  the  true 
pelvis  in  the  last  two  weeks  of  pregnancy,  while  it  improves  the  respiration 
and  circulation  in  general,  does  not  relieve  the  renal  venous  stasis.  While 
most  women  feel  lighter  and  freer  during  these  last  two  weeks,  owing  to  the 
settling  down  of  the  fetus  from  the  shortening  of  the  cervix,  the  intra- 
abdominal and  pelvic  pressure  is  not  diminished. 

So  great  is  the  significance  of  albuminuria  during  pregnancy  that  its  pres- 
ence should  always  be  watched  for.  Frequent  physical,  chemical,  and  micro- 
scopical examinations  of  the  urine  should  be  made  in  the  latter  mouths  of 
pregnancy.  If  the  presence  of  albumin  is  but  slight,  it  may  be  physiological, 
or,  if  pathological,  no  noticeable  symptoms  may  be  observed  ;  but  if  it  is  con- 
siderable and  persistent,  and  if  it  occurs  early  in  pregnancy,  the  prognosis  is 
grave.  Albuminuria  is  then  a  condition  full  of  ill  omen,  although  it  is  always 
susceptible  of  amelioration  by  well-directed  treatment,  and  in  many  cases  it 
may  entirely  be  overcome. 

From  a  clinical  standpoint  it  is  ordinarily  presumed  that  when  there  is 
albuminuria  there  is  also  uremia  to  a  corresponding  degree.  Doubtless  it  is 
true  that  when  albumin  is  abnormally  excreted  by  the  kidneys  there  is  some 
retention  of  urea  in  the  blood,  from  defective  action  of  the  kidneys,  but 
certainly  these  two  functional  disorders  do  not  hold  the  same  proportion  or 
relation.  There  may  be  much  albuminuria  and  but  little  uremia,  and  vice 
versd.  It  is  the  degree  of  the  latter  disorder  that  forebodes  evil.  The 
whole  line  of  treatment  should  be  directed  toward  favoring  the  elimination 
from  the  blood  of  this  poisonous  material  of  urea,  with  its  products.  To  secure 
this  result  it  is  incumbent  upon  us  to  act  as  potently  as  we  can  upon  the 
bowels  and  the  skin — compensator)'  organs  of  the  kidneys — and  to  address  our 
remaining  treatment  to  controlling  other  symptoms  that  may  arise. 

Changes  in  the  Nervous  System. — The  nervous  system  becomes  more  impres- 
sionable in  pregnaucy.  The  emotional  susceptibility  is  markedly  increased 
and  the  whole  character  is  altered.  A  woman  may  become  fretful,  peevish,  irri- 
table, and  at  times  unreasonable.  The  most  amiable  woman  may  thus  be  dis- 
posed when  pregnant.  She  is  often  depressed  in  spirits  at  first,  when  her 
general  nutrition  is  impaired  from  an  imperfect  appetite  or  a  faulty  digestion. 
Mania  may  be  excited  later  ou — easily  in  those  who  are  thus  predisposed  by 
inheritance  or  by  actual  melancholia.  These  conditions  are  among  the  most 
troublesome  of  the  various  complications  of  pregnancy.  To  witness  a  woman 
in  the  process  of  child-bearing  impaired  in  her  mental  functions  is  indeed  sad. 
There  are  cases,  however,  in  which  a  sense  of  well-being  takes  the  place  of 
one  of  more  or  less  physical  debility.  A  condition  of  want  of  mental  and 
physical  activity  before  pregnancy  at  times  becomes  changed  to  one  of  buoy- 
ancy and  exhilaration.  Physically  such  women  are  stronger,  and  mentally 
they  are  more  active  and  energetic.  No  factor  enters  so  much  into  the 
causation  of  this  mental  cheer  and  despondency  as  the  psychical — the  degree 
of  the  desire  for  an  offspring. 


DIAGNOSIS    OF  PREGNANCY.  161 


II.  DIAGNOSIS  OF  PREGNANCY. 

1.  Symptoms  and  Signs  of  Pregnancy. 

1.  The  Nausea  and  Vomiting  of  Pregnancy,  called  the  "Morning- 
Sickness." — This  symptom  consists  of  nausea,  accompanied  often  with  vomit- 
ing or  the  retching  of  a  glairy  fluid,  showing  itself  early  in  the  morning,  gen- 
erally before,  at  times  only  after,  breakfast.  The  assumption  of  the  erect 
posture  seemingly  excites  the  disorder.  Sometimes  it  begins  very  early,  within 
a  few  days  after  conception,  but  usually  not  until  the  fourth  or  the  fifth  week 
of  pregnancy.  Seldom  does  it  persist  throughout  pregnancy,  but  generally 
ceases  spontaneously  within  the  fourth  month,  although  it  may  continue 
throughout  the  whole  period.  In  many  or  in  most  cases  it  is  comparatively 
mild,  and  does  not  seriously  impair  the  health,  its  presence  being  regarded  as 
a  favorable  omen ;  but  as  there  is  every  degree  of  seriousness  in  its  nature,  it 
is  at  times  so  severe  and  so  long  continued  that  not  only  are  parts  of  meals 
vomited,  but  all  foods,  of  whatever  kind,  variety,  or  quantity,  are  also  rejected. 
Not  only  may  the  ingestion  of  food  excite  vomiting,  but  the  sight  or  the  smell 
of  food  may  also  give  rise  to  this  characteristic  nausea. 

Morning  sickness  is  a  sympathetic  disorder  reflected  from  the  uterus. 
There  is  no  more  satisfactory  explanation  of  the  manifestation  of  these  phe- 
nomena than  that  they  are  a  reflex  irritation  of  the  sympathetic  nervous  sys- 
tem, due  to  expansion  of  the  uterus.  The  erect  posture  quickly  assumed  always 
increases  the  congestion  of  the  uterus,  and  thereby  aggravates  its  irritability. 
It  is  aggravated  by  unpalatable  food,  by  posture,  by  sexual  excitement,  and 
by  emotional  disturbances.  It  is  most  marked  in  first  pregnancies,  and  in 
women  of  highly  nervous  organization — a  fact  ever  to  be  considered  in  the 
management  of  this  affection.  It  comes  on  almost  immediately  in  a  few 
instances ;  usually  not  until  the  sixth  or  seventh  week  of  pregnancy.  Some 
irritations  of  the  pelvic  organs  may  produce  the  same  result,  viz.,  uterine  dis- 
placements and  inflammation  of  the  peri-uterine  organs.  Seldom  is  it  com- 
pletely absent.  It  is  a  suspicious  or  presumptive  evidence  taken  by  itself,  but 
when  associated  with  certain  other  symptoms  and  signs  it  becomes  a  more  prob- 
able symptom  of  pregnancy.  Not  necessarily  in  the  regular  order  of  time,  but 
quite  generally  associated  with  this  morning  sickness,  there  are  certain  morbid 
longings  for  food  ;  for  instance,  foods  and  drink  and  certain  vegetable  acids 
formerly  disliked  are  now  desired  ;  the  most  unpalatable  substances,  such  as 
chalk,  clay,  aud  slate-pencils,  may  be  craved ;  or  there  may  be  a  distaste  for 
the  usual  articles  of  diet.  Other  stomach  disorders,  such  as  acidity,  flatulency, 
heartburn,  and  unpleasant  eructations,  are  sometimes  noticed. 

Salivation  is  a  very  common  accompaniment  of  the  morning  sickness  when 
the  latter  is  severe.  A  constant  dribbling  of  the  saliva  by  day  or  by  night 
occurs  in  the  earlier  months  of  pregnancy,  and  its  severity  aud  duration 
remain  for  an  uncertain  period.  It  has  been  observed  to  continue  for  mouths 
after  the  abatement  of  the  nausea  aud  vomiting. 


162  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

Toothache. — Under  the  above  heading  may  also  be  included  toothache, 
which  at  times  is  a  purely  functional  disorder ;  more  often  it  is  a  symptom 
of  actual  caries,  arising  from  alteration  of  the  buccal  secretion,  dissolving  the 
lime-salts  of  the  enamel  of  the  teeth ;  or  it  may  be  the  result  of  a  morbid 
determination  of  the  ossific  elements  of  the  teeth  of  the  mother  to  the  bones 
of  the  growing  fetus. 

2.  Menstrual  Suppression. — The  second  symptom  more  or  less  express- 
ive of  the  existence  of  pregnancy  is  the  suppression  of  the  menses.  The 
function  of  menstruation  is  almost  always  suspended  throughout  the  whole 
period  of  pregnancy.  So  reliable  is  this  symptom  that  the  determination  of 
the  end  of  gestation,  or  the  time  for  the  expected  parturition,  is  best  obtained  by 
adding  from  two  hundred  and  seventy-eight  to  two  hundred  and  eighty  days 
to  the  date  of  appearance  of  the  last  menstrual  flow.  But  not  invariably  is 
menstruation  suspended  following  an  impregnation.  The  most  frequent  ex- 
ception to  the  general  rule  is  found  when  menstruation  returns  once  only ;  then 
it  is  usually  for  a  somewhat  shorter  time  and  in  diminished  quantity.  The 
occurrence  of  a  menstrual  flow  in  diminished  quantity  and  for  a  shorter  time 
in  a  married  woman  who  has  had  her  menstrual  periods  regular  as  to  time, 
quantity,  and  duration  is  very  significant  of  a  possible  pregnancy,  and  the 
conception  must  have  occurred  several  days  before  this  function  last  appeared. 
Again,  by  way  of  exception  to  the  rule,  there  are  recorded  notable  instances  in 
which  the  period  of  pregnancy  was  attended  by  a  regular  menstruation.  The 
writer  recalls  in  his  experience  the  case  of  a  woman,  now  living  and  in  health, 
who  never  menstruated  before  marriage,  nor  during  her  married  life  of  several 
vears  unless  she  became  pregnant.  She  had  no  menstruation  the  first  two  years 
of  her  married  life  until  pregnant,  and  there  was  no  return  of  the  menstrual 
flow  until  she  was  agaiu  pregnant ;  in  other  words,  menstruation  in  this  case 
was  never  present  except  during  pregnancy,  M'hen  it  was  normal  in  all  regards, 
havino-  thus  appeared  in  three  distinct  pregnancies.  Possibly  the  periodic 
hemorrhage  in  this  case  was  of  cervical  origin,  but  no  pathological  lesion  of 
the  uterus  could  be  detected.  Menstruation  occurring  during  the  first  three 
months  of  pregnancy,  as  it  does  sometimes,  though  more  scantily,  may  come 
from  the  decidual  cavity  of  the  uterus,  not  yet  closed,  before  the  decidua  vera 
and  the  decidua  reflexa  have  become  agglutinated  ;  then  there  must  have 
been  a  certain  amount  of  chronic  decidual  endometritis — a  morbid  state,  of 
course. 

As  many  causes  purely  pathological — general  and  local,  physical  and 
psychical — induce  menstrual  suppression,  the  exact  significance  or  the  relative 
value  of  this  symptom,  as  an  evidence  of  the  existence  of  pregnancy  deserves 
most  careful  consideration.  For  instance,  meustrual  suppression  following 
months  and  years  of  menstruation,  normal  in  all  regards,  is  a  very  strong  sus- 
picion of  pregnancy.  Its  value  as  evidence  becomes  less  when  it  is  stopped 
in  a  woman  whose  previous  periods  have  been  irregular  from  any  cause.  This 
symptom  of  menstrual  suppression  cannot,  of  course,  be  present  from  preg- 
nancy when  the  menses  are  physiologically  absent  from  lactation,  or  when  the 


DIAGNOSIS   OF  PREGNANCY.  163 

pregnancy  occurs  before  the  first  menstrual  appearance,  prior  to  puberty  or 
after  the  menopause.  So  much  faith  has  the  popular  mind  in  the  presence  of 
this  symptom  of  menstrual  suppression  as  indicative  of  pregnancy  that  no 
small  degree  of  anxiety  in  looking  forward  to  a  pregnancy  is  often  manifested 
by  women.  The  fear  of  impregnation  in  the  unmarried  after  illicit  sexual 
intercourse,  the  expectation  of  the  same  in  the  newly  married,  the  ever-pres- 
ent hope  of  maternity  in  the  sterile  woman,  and  the  seeming  appearances  of 
pregnancy  in  some  cases  of  abdominal  enlargements,  are  mental  states  which 
may  suspend  the  normal  regularity  of  menstruation.  There  is  what  is  called 
"  psychical  amenorrhea,"  in  which  case  menstruation  is  suspended  or  is 
delayed  from  purely  psychical  causes.  While  it  affects  newly-married 
women  who  may  be  anxious  to  avoid  pregnancy,  it  concerns  mostly  unmar- 
ried women  who  have  exposed  themselves  to  the  possibility  of  impregnation. 
The  fear  of  a  possible  pregnancy  is  doubtless  sufficient  to  prevent  a  normal 
return  of  this  function.  The  exceptions  of  the  cessation  of  menstruation 
without  pregnancy,  in  seeming  good  health,  and  the  continuance  of  this  ute- 
rine function  with  pregnancy,  are  very  often  misleading. 

All  the  exceptions  above  mentioned  should  be  remembered  when  esti- 
mating the  actual  worth  of  the  symptom  of  menstrual  suppression.  We 
should  ever  bear  in  mind,  however,  that  the  patient's  statements  are  not 
always  to  be  relied  upon. 

3.  Mammary  Changes. — During  pregnancy  the  mammary  glands  are  in 
immediate  sympathy  with  the  growing  reproductive  organs  of  the  pelvis,  con- 
sequently a  genuine  physiological  hypertrophy  commences  in  these  organs 
from  the  beginning  of  gestation.  Their  glandular  structures  become  larger, 
fuller,  and  firmer ;  a  sensation  of  weight  or  of  pricking  in  them  is  felt  by  the 
patient ;  the  veins,  blue  in  color,  become  enlarged  and  more  visible.  Light- 
colored,  silvery  lines  are  seen  radiating  over  the  projecting  organs  in  the  last 
months  of  pregnancy.  The  nipples  also  become  enlarged,  more  elongated,  prom- 
inent, and  somewhat  erect  (Pis.  17, 18).  Surrounding  the  nipple  is  noticed  the 
areola,  which  becomes  darker  in  color,  and  which  is  most  pronounced  in  bru- 
nettes (PI.  17).  Two  or  more  enlarged  moist  follicles,  varying  in  size  and  con- 
taining sebaceous  material,  are  seen  projecting  from  the  surface  of  the  areola. 
In  the  fifth  or  the  sixth  month  there  appears  a  secondary  areola  (Pis.  17, 18)  con- 
sisting of  scattered  round  spots,  appearing  as  if  the  color  had  been  discharged 
as  a  shower  of  drops  (Montgomery).  Thus  every  structure  entering  into 
the  composition  of  the  mammary  glands  is  physiologically  hypertrophied. 
These  changes  begin  as  early  as  the  second  month,  and  become  more  pro- 
nounced as  pregnancy  proceeds.  The  two  mammary  glands  are  equally 
enlarged  and  progressively  developed.  The  secretion  of  colostrum  in  the 
glands  enhances  the  value  of  these  mammary  changes  indicative  of  pregnancy, 
especially  if  noticed  in  women  who  have  never  before  been  pregnant.  Milk  is 
now  and  then  seen  to  ooze  from  the  nipples  of  some  women  before  delivery 
(PI.  17);  in  most  women  a  drop  or  more  of  colostrum  may  be  squeezed  from 
the  nipples  after  the  third  month.     Instead  of  the  lacteal  secretion  being  pro- 


164  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

moted,  its  suppression  in  nursing  women  is  very  suspicious  of  another  preg- 
nancy. Milk  is  secreted  at  times,  though  rarely,  when  there  is  no  pregnancy. 
Pelvic  diseases,  such  as  chronic  metritis,  rapid-growing  fibroids,  ovarian  cysto- 
rnata,  and  false  pregnancy,  at  times  induce  milk-secretion.  In  some  women 
the  mammary  glands  display  a  noticeable  physiological  activity  at  each  cata- 
menial  epoch — even  to  a  free  milk-secretion.  Cases  are  recorded  of  the 
presence  of  milk  in  the  mammary  glands  of  males.  These  characteristic 
physiological  changes,  in  their  uniformity  and  progressiveness,  mark  the 
distinguishing  differences  between  the  mammary  changes  of  pregnancy  and 
those  alterations  noticed  in  size  and  shape  of  the  glands  from  sympathy  with 
cei'tain  pelvic  diseases — ovarian  and  uterine. 

These  mammary  changes  in  structure,  color,  and  function  are  of  little  diag- 
nostic value  when  considered  alone,  but  when, taken  in  conjunction  with  other 
symptoms  they  are  highly  probable  evidences,  especially  in  first  pregnancies. 
Owing  to  the  fact  that  the  darkening  of  the  areola  in  multiparas,  and  the 
erectility  of  the  nipple  remain  more  or  less  prominent,  while  colostrum  may 
sometimes  be  present  for  years  after  the  cessation  of  lactation,  it  can  be  ap- 
preciated how  these  signs  lose  their  diagnostic  value  in  women  who  have  borne 
children. 

4.  Functional  Disturbances  of  the  Bladder. — Functional  disturbances 
of  the  bladder  are  quite  often  noticeable  early  in  pregnancy.  As  the  bladder 
is  somewhat  dragged  upon  by  the  physiological  prolapsus  of  the  uterus  in  the 
first  mouth  (a  position  rather  increased  in  the  second  month),  and  as  it  is  pressed 
upon  during  the  third  month  by  the  increasing  normal  anteversion,  it  can  be 
understood  why  functional  disorders  of  this  organ  may  result.  The  bladder- 
capacity  is  diminished,  and  in  consequence  there  is  an  increased  frequency  of 
urination.  The  vesical  symptoms  tend  to  diminish  in  the  fourth  month, 
because  of  the  ascent  of  the"  uterus  from  the  pelvic  to  the  abdominal  cavity. 
If  retroversion  of  the  uterus  existed  prior  to  pregnancy,  this  backward  mal- 
position is  increased,  while  the  uterus  is  pelvic  in  position.  Because  of  the 
increasing  size  of  the  organ,  with  its  growing  contents,  there  follows,  at  times, 
from  retroversion,  serious  urinary  retention.  Incontinence  of  urine  more 
rarely  occurs  during  pregnancy,  from  coughing  or  from  sneezing,  when  the 
bladder  is  somewhat  distended.  Some  degree  of  irritability  of  the  bladder 
is  apparent  in  almost  all  pregnant  women,  aud  it  occurs  to  an  exaggerated 
degree  in  neurotic  individuals  when  the  pressure  of  the  gravid  uterus  is 
more  manifest. 

Kiestein,  sometimes  present  in  pregnant  women,  is  a  proteiue  substance, 
consisting  of  triple  phosphates,  fungi,  and  infusoria,  that  forms  like  a 
flocculent  cloud  on  the  urine  kept  standing  for  a  few  days  at  a  tem- 
perature of  70°  F.  It  occurs  iu  the  urine  from  the  eighth  to  the  thirty- 
second  week  of  pregnancy,  then  disappears.  It  has  practically  no  diag- 
nostic value,  as  it  is  found  in  the  uriue  of  non-pregnant  women,  and  at 
times  in  that  of  men. 

5.  Intrapelvic    Signs. — Certain  changes   in   structure  take   place  in  the 


PREGNANCY. 


Secondary  areola  uf  usual  size  (in  a  brunette).  Secondary  areola,  prominently  marked  (S),  with 

wide  primary  (P)  areola  (in  a  brunette;. 


Mammary  signs  of  pregnancy  in  their  order  (two -thirds  life  size). 


PREGNANCY. 


Plate  18. 


Elevation  of  primary  areola  (E)  in  profile,  o 
pared  with  au  areola  which  is  not  elevated  (ci 
posite  photograph). 


Well-formed,  firm  breast  and  nipple  (in  a  brunette). 


Typical  signs  in  the  blonde:  F,  follicles ;  PA,  pri- 
mary areola. 


Mammary  signs  of  pregnancy. 


DIAGNOSIS    OF  PREGNANCY. 


165 


uterus  in  the  earlier  months  of  pregnancy,  when  the  organ  is  confined  within 
the  true  pelvis,  before  it  ascends  within  the  abdominal  cavity ;  these  changes, 
carefully  studied  and  detected  by  vaginal  touch  and  by  bimanual  exami- 
nation, possess  a  significance  far  greater  than  any  of  the  aforementioned  symp- 
toms. Associated  with  some  of  the  other  symptoms,  these  changes  become 
extremely  probable  evidences : 

(a)  Softening  and  Enlargement  of  the  Cervix  Uteri. — These  changes,  com- 
pared with  the  physical  conditions  of  the  same  parts  in  the  virgin  or  the 
never-pregnant  woman,  will  be  observed  to  be  quite  characteristic — less  so 
in  women  who  have  borne  children.  The  cervix  uteri  softens  and  enlarges 
in  all  directions  as  the  result  of  the  increased  blood-supply  and  the  edema 
of  the  parts.  The  lips  of  the  os  uteri  become  patulous  and  puffy,  a  condition 
most  noticeable  in  primiparse.  The  softening  of  the  infravaginal  cervix, 
beginning  below,  extends  upward.  The  cervical  secretion  of  mucus,  the 
so-called  "  cervical  plug,"  is  increased.  Rapidly  growing  myomata  may 
likewise  soften  the  cervix.  But  should  the  cervix  uteri  be  the  seat  of  some 
old  injury,  and  a  dense  cicatricial  tissue  result,  then  there  will  be  no  appre- 
ciable softening  from  pregnancy. 

The  diminished  resistance  to  touch  and  the  increasing  width  of  the  tissues 
seemingly  shorten  the  cervix.  These  changes,  while  beginning  in  the  first 
mouth,  are  not  recognizable  until  the  second  month  ;  from  this  time  they  are 
progressive. 

Erroneous  views  as  to  changes  in  the  cervix  uteri  during  pregnancy  existed 
in  years  past.  It  was  believed  that  the  cervical  canal  was  greatly  shortened 
to  form  part  of  the  corporeal  cavity,  and  that  toward  the  last  of  pregnancy  no 
cervical  cavity  existed,  it  having  lost  one-half  its  length  by  the  sixth  month, 
and  so  on,  until  it  was  obliterated  in 
the  eighth  and  ninth  mouths.  These 
views,  long  entertained,  were  in  1826 
called  in  question  by  Stolz,  whose  views 
most  modern  obstetricians  now  uphold. 
Post-mortem  examinations  made  of 
women  in  advanced  pregnancy  —  the 
best  proofs — have  established  the  fact 
that  the- cervix  maintains  its  length  of 
2.5  centimeters  (1  inch)  or  more  to  the  F 
last  days  of  pregnancy  (Fig.  137). 
Digital  exploration  through  the  patulous  cervix  substantiates  this  fact.  But 
during  the  fortnight  preceding  parturition  a  genuine  broadening  of  the  cer- 
vix takes  place,  when  the  cervical  canal  is  merged  into  the  upper  uterine 
cavity — a  result,  no  doubt,  of  the  incipient  uterine  contractions  preparatory 
to  labor,  as  pointed  out  by  Matthews  Duncan. 

The  broadening  of  the  cervix  in  the  last  stage  of  pregnancy,  prior  to 
eight  and  one-half  months,  then,  is,  seemingly,  not  real  until  the  last  fort- 
night.    More  or  less  of  these  changes  remain  eveu  after  parturition  ;  in  other 


f 

-Cervix  at  end  of  pregnancy  (Waldeyer). 


166  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

words,  the  cervix  does  not  completely  resume  its  pristine  virgin  firmness  and 
smoothness  of  surface  or  its  original  size. 

While  these  changes  are  noticeable  from  pathological  as  well  as  from 
physiological  causes,  their  value  in  the  diagnosis  of  pregnancy  is  only  to  be 
relied  upon,  when  associated  with  other  signs  and  when  taken  in  conjunction 
with  certain  other  symptoms. 

(b)  The  Violet  Color  of  the  Vulvar  and  Vaginal  Mucous  Membrane. — 
Dr.  Jacquemin  of  Paris  first  discovered  this  sign,  and  Dr.  Chadwick  of  Boston 
has  fully  dwelt  upon  its  diagnostic  significance.  Inspection  reveals  its  pres- 
ence, most  distinctly  on  the  inner  surface  of  the  labia  majora  and  the  vaginal 
mucous  membrane  of  the  anterior  wall,  exposed  when  the  labia  are  separated. 
This  pigmentation  begins  in  some  cases  as  early  as  the  fourth  week.  It  is 
of  importance  in  the  earlier  months  of  pregnancy,  when  there  is  seen  the 
then  pale  violet  color,  becoming  more  bluish  as  pregnancy  advances.  But 
this  sign  is  not  of  positive  value,  for  it  is  at  times  entirely  absent  in  early 
pregnancy.  While  arising  from  a  venous  stagnation  in  the  vaginal  vessels, 
it  may  come  also  from  vaginal  or  uterine  congestion  due  to  disease.  This 
sign  is  valuable  often  as  early  as  the  second  month,  and  in  the  latter  half  of 
pregnancy  it  is  highly  diagnostic ;  then  its  recognition  possesses  great  value. 

(c)  Hegar's  sign,  which  has  been  given  to  the  profession  within  the  lasi 
decade,  possesses  a  great  advantage.  In  all  doubtful  conditions  of  early  preg- 
nancy this  sign  ought  to  be  searched 
for.  It  is  to  be  detected  by  vaginal 
touch  and  by  bimanual  examination. 
Its  presence  implies  a  change  in  the 
consistency  of  the  lower  uterine  seg- 
ment. The  greatest  changes  in  the 
uterus  must  and  do  take  place  in  the 
body  of  this  organ — the  bed,  as  it  were, 
for  the  growing  ovum.  The  neck  of  the 
womb  is  less  supplied  with  blood,  and 
it  receives  comparatively  little  of  the 
stimulus  of  pregnancy.  The  develop- 
ment of  the  cervix  is  largely  completed 
by  the  fourth  month.  During  the 
first   six  or    eight  weeks  of  gestation 

fig.  i3s.-Pregnant  uterus  of  early  part  of   the  body  of  the  uterus  enlarges,  espe- 

tbird  month  (Braun's  frozen  section),  with  prob-       .....  .*"-.. 

able  post-mortem  retroversion :  d,  d,  decidua  vera.    Chilly  in   its    autero-postenor    diameter. 

Bimanual,  recto-vaginal,  or  abdomino- 
vaginal touch  will  detect  some  enlargement  in  all  directions — anterior,  pos- 
terior, and  lateral.  The  lower  uterine  segment  becomes  soft,  compressible, 
and  pulsating;  above  there  is  the  projecting  or  bulging  uterine  wall,  hard  and 
resisting  during  uterine  contraction,  boggy  or  soft  during  relaxation.  The  ac- 
companying illustrations  (Figs.  138-140)  best  elucidate  these  facts.  The  uterus 
in  shape  has  been  likened  to  that  of  a  demijohn,  to  an  old-fashioned  fat-bellied 


DIAGNOSIS    OF   PREGNANCY. 


167 


jug,  or  to  a  sphere  (corpus)  resting  upon  a  cylinder  (cervix).  These  altera- 
tions in  consistency,  while  noticed  on  the  posterior  wall  by  rectal  touch,  are 
best  detected  along  the  anterior  uterine  wall  by  the  finger  in  the  vagina  with 


Fig.  139.— Longitudinal  section  of  a  nulliparous  (a)  and  of  a  muciparous  (e)  uterus  :  A,  cavity  of  trie 
cervix  and  arbor  vitae ;  C,  cavity  of  the  body ;  0,  constriction  between  body  and  cervix,  the  os  uteri 
internum :  S,  wall  of  body  (Tarnier). 

the  outer  hand  on  the  abdomen  seizing  the  uterus.  The  structures  of  the 
corporeal  wall  may  become  soft  and  yielding,  and  may  show  a  contrast  with  the 
cervix  below.  It  is  true  that  the  sign  of  bogginess  of  the  body  is  not  always 
present,  and  that  its  presence  is  simidated  somewhat  by  morbid  states,  but  the 
peculiar  compressibility  of  the  lower  segment,  together  with  the  bogginess  of  the 
body  and  the  changes  in  shape  of  the  womb,  is  not  simulated  by  anything 
else.  This  enlargement  of  the  uterus,  with  the  change  in  its  shape,  size,  and 
consistency,  are  the  most  important  signs  of  pregnancy  in  the  earlier  weeks. 

(d)  Changed  Position  of  the  Uterus. — We  must  not  fail  to  bear  in  mind 
the  modification  in  the  positions  of  the  uterus  that  pregnancy  usually  produces. 


Fig.  140.— Frozen  section  of  uterus  at  two  and  a  half  months  (Pinard),  showing  relaxed  and  thin 
walls,  thickened  decidua ;  with  the  clinical  findings  of  Figure  139  it  will  be  seen  how  the  bimanual 
signs  originated. 

In  the  first  and  second  months  the  uterus  is  somewhat  lower,  but  in  the  third 
month  it  undergoes  an  increased  anteversion,  for  the  reason  that  the  relatively 
increasing  weight  of  the  body  of  the  uterus  with  its  growing  contents  tilts  the 
upper  end  of  the  uterine  lever  downward  and  forward.     Some  anteflexion 


168  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

there  appears  with  the  actual  anteversion.  This  change  in  position  will 
be  noticed  in  all  cases  except  those  in  which  pregnancy  has  occurred  in  a 
previously  retroverted  uterus ;  the  retroversion  is  then  increased.  This 
statement  is  made,  notwithstanding  that  some  of  this  anteversion  may  be 
apparent,  not  real,  the  anteroposterior  diameter  of  the  organ  being  thickened. 

Hegar's  sign,  recognized,  as  it  may  be,  so  early  as  the  second  month, 
and  the  overhanging  and  softness  of  the  corpus,  the  changed  position  of  the 
uterus,  and  the  violet  color  of  the  vagina  and  cervix  uteri,  while  not  abso- 
lutely positive  signs,  are  highly  probable  evidences  when  associated  with 
some  of  the  rational  symptoms  referred  to.  They  possess  a  diagnostic  sig- 
nificance ever  to  be  watched  for  and  carefully  estimated.  They  are  a  corn- 
plexus  of  physical  signs  that  gives  a  reasonable  diagnostic  certainty. 

6.  Abdominal  Changes. — Under  this  head  are  included  all  those  changes 
in  size,  shape,  and  appearance  of  the  abdomen  that  may  take  place. 

(a)  Enlargement,  Size,  and  Shape  of  the  Abdomen. — At  first,  during  the 
first  six  to  eight  weeks,  there  is  somewhat  of  a  flattening  of  the  abdominal 
surface,  due,  doubtless  to  the  descent  of  the  uterus  into  the  pelvic  cavity,  thus 
slightly  dragging  the  bladder  downward  and  making  traction  on  the  urachus, 
thereby  drawing  the  umbilicus  inward.  The  navel  in  consequence  becomes 
depressed  ;  hence  the  common  expression,  "  A  blank  before  a  bank."  Later 
in  the  fourth  month,  as  the  growing  uterus  rises  for  proper  accommodation 
in  the  abdominal  cavity,  a  slight  abdominal  enlargement  will  be  observed, 
and  the  umbilicus  is  no  longer  sunken.  By  the  fourth  month  the  fundus 
uteri  has  risen  about  5  centimeters  (2  inches)  above  the  symphysis  pubis.  The 
vertical  enlargement  progresses  at  the  rate  of  fully  two  fingers'  breadth  each 
four  weeks,  reaching  the  umbilicus  at  the  end  of  the  sixth  month,  and  touch- 
ing the  eusiform  cartilage  at  the  end  of  thirty-eight  weeks,  or  eight  and  a  half 
lunar  mouths  (PL  19,  Fig.  1).  The  umbilicus  for  many  weeks  prior  to  that 
time  has  been  protruding.  During  the  last  two  weeks  of  utero-gestation  the 
upper  portion  of  the  abdominal  walls  protrudes  less  and  the  girth  of  the  woman 
seems  smaller  (PI.  19,  Fig.  2).  The  patient  feels  more  comfortable.  The  cer- 
vical canal  is  apparently  shortened,  the  child  in  utero  has  sunken,  and  the  pelvic 
ligaments  are  relaxed — changes  preparatory  to  the  coming  parturition.  During 
this  time  it  will  be  noticed  that  the  enlarging  pregnaut  womb  is  symmetrical, 
smooth  in  its  contour,  larger  vertically  than  transversly,  and  by  proper  pal- 
pation it  will  be  felt  to  contract  spontaneously.  Twin  pregnancies,  breech 
and  transverse  presentations,  some  deformities  of  the  fetus,  and  some  obliqui- 
ties of  the  pelvis  may  alter  the  shape,  the  size,  and  the  degree  of  enlargement 
of  the  abdomen. 

(b)  Coloration. — On  inspection  of  the  abdomen  of  pregnant  women  there 
will  be  recognized  not  only  the  condition  of  the  navel,  but  also  a  changed 
color  of  the  abdominal  surface,  and  the  presence  of  strise,  due  to  distention  of 
the  abdomen.  The  pigmentation  may  extend  from  the  pubis  to  the  xiphoid 
cartilao-e — the  brown  lines.  On  the  sides  of  the  abdominal  walls  and  down 
the  thighs  red,  blue,  or  white  markings,  like  cicatrices,  may  be  seen. 


PEEGNANCY. 


DIAGNOSIS   OF  PREGNANCY.  169 

(c)  Fetal  Movements. — Fetal  movements  are  generally  visible  after  the  sixth 
month  through  the  abdominal  parietes. 

7.  Ballottement. — Ballottement  is  a  passive  motion  of  the  fetus,  consist- 
ing of  the  peculiar  sensation  felt  by  the  examining  fingers  upon  giving  the 
fetus  a  motion  in  utero.  Vaginal  ballottement  is  usually  employed,  although 
abdominal  ballottement  is  also  practicable  at  times,  and  may  be  noticed  for  a 
longer  period  of  time,  even  during  the  beginning  of  labor.  For  the  ballotte- 
ment impulse  to  be  perceptible  there  must  be  a  mobile  fetus,  not  too  large,  and 
a  sufficient  quantity  of  the  liquor  amuii  to  permit  the  entire  fetal  displace- 
ment in  utero.  The  woman  stands  or  reclines  during  its  performance.  In  the 
vaginal  ballottement  the  finger  is  placed  within  the  vagina,  anterior  to  the 
cervix,  the  pulp  of  the  finger  being  applied  to  the  anterior  vaginal  fornix  by 
a  direct  brisk  motion.  The  fetus  is  propelled  upward  into  the  uterine  cavity, 
and,  falling  back  by  its  gravity,  an  impulse  is  imparted  to  the  finger  against 
which  it  falls. 

Ballottement  distinctly  noticed  is  a  pathognomonic  sign  of  pregnancy, 
there  being  no  other  condition  in  which  a  solid  body  is  found  floating  in  the 
uterine  cavity.  The  absence  of  this  sign  does  not  preclude  the  possibility  of 
pregnancy,  for  different  conditions  may  prevent  its  being  noticed,  such  as  ex- 
cessive or  great  diminution  in  size  of  the  fetus,  hydramnios,  multiple  preg- 
nancy, some  abnormal  presentation,  or  a  faulty  insertion  of  the  placenta. 

Vaginal  ballottement  can  sometimes  be  practised  successfully  as  early  as 
the  latter  part  of  the  fourth  month.  It  is  more  easily  recognized  in  the  fifth 
month,  is  most  distinct  in  the  sixth,  continues  in  the  seventh,  is  doubtful  in 
the  eighth,  and  is  absent  in  the  ninth  mouth. 

8.  Intermittent  Contractions. — As  soon  as  the  uterus  is  developed  suf- 
ficiently to  be  felt  by  the  hand  through  the  abdominal  wall,  there  may  be 
perceptible  intermittent  uterine  contractions  which  are  constantly  going  on  at 
intervals  of  a  few  minutes  throughout  pregnancy.  Purely  independent  of 
volition,  they  may  become  valuable,  in  a  diagnostic  sense,  in  corroborating 
other  signs.  Uterine  contractions  are  not  positive  signs,  because  the  uterus 
undergoes  somewhat  similar  contractions  to  free  itself  of  clots  of  blood,  of 
polypoid  or  fibroid  tumors,  and  of  retained  secundines,  or  they  may  be  simu- 
lated by  a  distended  bladder. 

The  method  of  procedure  for  detecting  uterine  contractions  is  to  grasp  the 
fundus  uteri  for  from  five  to  twenty  minutes,  with  the  patient  recumbent  on 
her  back,  the  uterus  meanwhile  being  lifted  by  the  right  finger  per  vaginam, 
the  abdominal  walls  being  relaxed  by  some  flexion  of  the  lower  limbs.  The 
characteristic  hardening  will  then  be  felt,  the  contraction  lasting  for  several 
minutes.  To  Braxton  Hicks  we  are  indebted  for  the  thorough  elucidation  of 
this  sign,  which  is  often  referred  to  as  "  Braxton  Hicks'  sign  of  pregnancy." 

9.  Quickening-  and  Fetal  Movements. — Quickening  is  the  sensation  ex- 
perienced by  the  mother  as  the  result  of  active  fetal  movements.  The  period 
when  these  active  movements  are  felt  is  quite  uncertain.  Usually  quickening 
is  considered  to  occur  about  the  middle  of  preguancy,  consequently  the  time 


170  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

of  expected  parturition  is  based  on  this  event,  but  very  unreliably.  Certain 
sensations  of  motion,  such  as  fluttering  or  pulsating,  are  sometimes  felt  by  the 
mother  earlier  than  these  active  motions.  As  pregnancy  advances  these  active 
motions  increase  in  frequency  aud  become  more  marked,  and  toward  the  last 
they  are  seen  very  generally.  When  felt  or  seen  by  the  physician,  as  can  be 
done  after  the  sixth  month,  fetal  movements  constitute  a  very  valuable  and 
positively  reliable  sign  not  only  of  pregnancy,  but  also  of  a  live  child  in  utero. 
This  sign  should  never  be  inferred  to  exist  from  the  statements  of  the  patient. 
Supposed  fetal  movements  are  frequently  felt  by  the  patient,  and  are  thought 
to  be,  but  are  not,  evidences  of  pregnancy  ;  frequently  they  are  only  illusory. 
These  seemingly  fetal  motions  come  from  the  abdominal  walls  in  false  preg- 
nancy or  from  the  intestines  in  tympanites. 

Failure  to  detect  fetal  movements  does  not  negative  pregnancy,  for  the 
child  may  be  dead  or  its  motion  may  not  be  felt.  To  detect  these  movements, 
place  the  patient  on  her  back  upon  a  table  or  a  bed,  with  the  thighs  flexed  and 
the  abdominal  walls  relaxed.  All  clothing  should  be  removed  from  the  abdo- 
men. By  palpation  and  renewed  pressure  at  different  parts  of  the  abdomen 
the  active  fetal  movements  may  be  detected ;  better,  sometimes,  by  applying 
the  hands  to  the  abdomen,  after  first  wetting  them  with  cold  water  to  excite  a 
reflex  action  of  the  fetus. 

10.  Uterine  Souffle. — This  murmur  lias  been  called  "placental,"  because 
it  was  thought  to  be  due  to  the  movement  of  the  blood  through  the  placental 
sinuses ;  it  has  also  been  named  the  "  abdominal  souffle,"  because  it  was 
thought  to  result  from  the  pressure  of  the  gravid  uterus  on  the  abdominal 
vessels.  Neither  of  these  two  theories  is  correct.  This  placental  murmur 
is  doubtless  due  to  the  movement  of  the  maternal  blood  through  the  uterine 
blood-vessels  ;  hence  it  should  be  called  "  uterine  souffle."  Heard  first  in  the 
fourth  month,  on  the  sides  of 'the  upper  part  of  the  uterus,  especially  the  left 
side,  which  for  obvious  reasons  is  brought  nearer  the  anterior  abdominal  wall, 
the  murmur  is  at  all  times  synchronous  with  the  maternal  pulsation.  It  is 
very  uncertain  as  to  its  presence,  tone,  pitch,  duration,  and  location  ;  if  once 
heard,  it  soon  leaves,  to  return  at  another  time  or  at  another  place.  It  is  thus 
usually  heard  irregularly  as  to  time,  place,  pitch,  and  duration  until  the  end 
of  pregnancy.  Uterine  souffle  is  no  longer  regarded  as  a  certain  proof  of 
pregnancy.  A  sound  exactly  resembling  it  is  not  unfrequeutly  heard  in  inter- 
stitial fibroids  of  the  uterus,  and  it  may  be  heard  when  ovarian  tumors  are 
present.  In  the  majority  of  cases  of  parturition  it  is  heard  for  the  first  two 
or  three  days  in  the.  lying-in  state. 

11.  Fetal  Heart-sounds. — These  sounds  are  a  comparatively  modern 
discovery.  Mayer  of  Genoa  first  heard  them  in  1818,  in  examining  the  abdo- 
men of  a  pregnant  woman.  The  fetal  heart-sound  cannot,  as  a  rule,  be 
heard  earlier  than  the  fifth  month  in  utero-gestation.  A  practised  ear  may 
sometimes  detect  it  a  few  weeks  earlier,  as  in  the  fourth  mouth.  As  this 
sound  becomes  stronger  and  louder  in  advancing  pregnancy,  its  detection  in 
the  last  few  months  becomes  very  easy.     The  sound  may,  of  course,  be  quite 


DIAGNOSIS   OF  PREGNANCY. 


171 


feeble.  If  normally  vigorous,  some  non-conducting  material,  as  a  tumor, 
an  abnormal  quantity  of  liquor  amnii,  or  very  thick  abdominal  walls,  may 
intervene,  impeding  its  transmission,  or  there  may  be  a  posterior  position  of 
the  child,  thus  making  it  less  distinct ;  hence  the  inability  to  hear  the  fetal 
heart-sound  ought  not  to  negative  a  pregnancy.  When  attempts  are  made 
for  its  detection,  the  room  should  be  quiet  and  the  patient  should  be  in  the 
dorsal  posture,  with  the  head  on  a  pillow  and  the  thighs  flexed  lightly  to 


Fig  141.— Location  and  intensity  of  fetal  heart-sounds  in  the  left  occipito-anterior  position  (the  four 
quadrants  are  indicated  by  the  red  lines ;  the  pose  is  from  Spigelius). 

the  body  or  extended.  The  stethoscope  ought  to  be  utilized,  from  motives  of 
modesty,  in  localizing  the  sound  of  the  fetal  heart.  This  instrument  should 
be  applied  to  the  abdomen  below  a  transverse  line  passing  through  the  umbili- 
cus, because  the  head  of  the  fetus  is  more  often  lower  thau  the  breech.  Since 
the  occiput  in  most  instances  points  toward  the  left  side  of  the  maternal  pelvis, 
the  fetal  heart-sound  is  most  frequently  heard  with  greatest  distinctness  upon 
the  left  lower  space  of  the  abdomen  (space  D,  Fig.  141).  If  not  heard  in 
this  space,  search  for  it  should  be  made  over  other  spaces  (as  b,  c,  a).     If 


172  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

heard  well  in  regions  c,  D,  the  inference  is  that  the  head  is  the  lowest  part  of 
the  fetus,  and  that  the  back  of  the  fetus  is  anterior ;  if  heard  best  in  regions 
A,  B,  it  is  to  be  inferred  that  there  is  a  pelvic  presentation. 

The  mean  frequency  of  the  pulsations  of  the  fetal  heart  is  about  from  130 
to  160  to  the  minute;  they  are  less  frequent  in  large  than  in  small  children,  and 
probably  are  less  frequent  in  males  than  in  females.  A  temporary  variation 
in  their  frequency  and  force  is  very  common.  The  sound  is  double  and 
rhythmic,  like  the  ticking  of  a  watch  under  a  pillow,  the  first  sound  being 
more  clear  and  distinct  than  the  second  ;  then  comes  a  brief  pause,  when  the 
second  sound  is  heard ;  a  longer  pause  follows  before  the  double  rhythmic 
sound  is  again  heard.  The  above-mentioned  frequency  indicates  that  there 
is  no  relation  of  the  fetal  heart-sound  to  the  pulsations  of  the  mother's  heart. 
These  two  sounds  are  perfectly  independent. 

Because  of  the  varying  frequency  of  the  fetal  heart-sounds,  attempts  have 
been  made  to  base  some  reliable  predictions  as  to  the  sex  of  the  fetus  in 
%der o ;  but  experience  has  proved  that  but  little  reliance  can  be  placed  on 
such  attempts. 

In  anterior  positions  of  the  vertex  the  tick  of  the  fetal  heart  is  heard 
with  a  maximum  intensity  to  the  left  or  to  the  right  of  the  median  line, 
slightly  below  the  umbilicus  ;  while  in  posterior  positions  of  the  vertex  it  is 
heard  in  the  flanks,  rather  higher  than  the  umbilicus  and  less  distinctly. 
The  position  of  the  fetal  heart-sound  in  this  way  is  a  valuable  help  in  the 
diagnosis  of  the  positions  of  the  fetus. 

The  sound  of  a  fetal  heart  well  heard  when  the  uterus-  is  relatively  small 
— too  small  to  accommodate  a  fetus  of  five  or  more  mouths'  development — 
should  at  once  create  suspicions  of  an  extra-uterine  pregnancy. 

As  auscultation  with  the  stethoscope  reveals  the  presence  of  the  uterine 
souffle  and  the  fetal  heart-sound,  the  practised  ear  may  also  detect  the  funic  or 
umbilical  souffle — an  intermittent  hissing  sound  synchronous  with  the  fetal 
heart.  It  is  referable  to  the  umbilical  cord.  It  is  heard  in  but  the  smallest 
number  of  cases,  and  its  causation  is  conjectural.  As  a  sign  of  pregnancy  it 
has  very  little  value. 

There  are  also  heard  sounds  produced  by  active  movements  of  the  fetus  in 
utero.  Fetal  movements,  for  instance,  may  be  heard  by  the  ear  instead  of 
being  felt  by  the  hand.     Their  value  is  significant. 

12.  Petal  Contour. — Inspection  of  the  shape  of  the  abdomen  in  preg- 
nancy is  also  valuable ;  a  careful,  well-trained  touch  by  palpation  may  detect 
the  size,  shape,  and  presentation  and  position  of  the  fetus,  as  well  as,  at  times, 
the  presence  of  twins  in  utero. 

Diagnosis  of  the  Sex  of  the  Fetus. — Almost  every  pregnant  woman  is 
anxious  to  know  the  sex  of  her  child  in  utero,  and  the  physician  is  very  often 
asked  for  an  expression  of  an  opinion. 

The  determination  of  this  matter,  by  estimating  the  rate  of  the  fetal  heart- 
beat— 120  to  140  in  the  minute — indicating,  it  is  said,  the  probability  of  a 
male,  while  a  quicker  beat  means  a  female,  is  very  unreliable. 


DIAGNOSIS   OF  PREGNANCY.  173 

Relative  ages  of  parents  are  probably  determining  factors,  in  a  measure, 
as  is  also  a  relative  physical  vigor  of  parents  at  the  time  of  sexual  congress. 

The  theory  of  the  time  of  fecundation  :  if  early  (within  a  few  days  before 
or  following  menstruation),  may  imply  a  female  ;  if  later,  a  male,  has  been 
advocated.     All  theories  are  mostly  speculative. 

13.  Mental  and  Emotional  Phenomena. — Pregnancy  quite  generally 
modifies  the  nature — physical,  mental,  and  emotional — of  a  woman.  At  times, 
she  is  more  vigorous,  buoyant,  and  cheerful  than  in  the  non-pregnant  state. 
More  generally,  however,  she  is  more  or  less  irritable,  excitable,  and  fretful. 
As  the  physical  appetites  for  food  in  quantity,  quality,  and  variety  are  fre- 
quently changed,  so  also  is  the  moral  sense  sometimes  seriously  deranged. 

Classification  of  the  Phenomena  of  Utero-gestation. — The  symptoms 
and  signs  of  pregnancy  may  now,  for  convenient  study,  be  classified  as  to  the 
time  of  their  occurrence.  For  instance,  the  nine  calendar  months  of  utero- 
gestation  may  be  divided  into  three  periods,  and  a  classification  may  be  made 
of  the  aforesaid  phenomena  as  to  these  three  periods. 

First  Period  of  Utero-gestation. — This  period  comprises  the  first  three 
calendar  months — the  time  during  which  the  gravid  uterus  is  enclosed  within 
the  true  pelvic  cavity.  The  symptoms  are — (1)  Menstrual  suppression;  (2) 
gastric  disorders ;  (3)  mammary  changes ;  (4)  vesical  irritation.  The  sign's 
are — (1)  Beginning  patulousness  of  the  os  uteri ;  (2)  softening  of  the  infra- 
vaginal  cervix,  gradually  extending  higher  ;  (3)  uterus  slightly  lowered  during 
the  first  and  second  months,  and  anteverted  in  the  third  month  ;  (4)  flattening 
of  the  abdomen,  with  increasing  depression  of  the  umbilicus,  the  depression 
gradually  disappearing  toward  the  fourth  month  ;  (5)  violet-colored  vaginal 
walls  and  cervix  uteri ;  (6)  Hegar's  sign  (compressibility  of  lower  uterine  seg- 
ment), with  softened  and  rounded  uterine  body. 

Second  Period  of  Utero-gestation. — This  period  embraces  the  fourth,  fifth, 
and  sixth  months.  The  signs  and  symj>toms  are — (1)  Menses  still  absent; 
(2)  subsidence  of  the  gastric  disturbances ;  (3)  increasing  and  progressive 
development  of  the  mammary  signs ;  (4)  vesical  irritation  improved ;  (5) 
the  uterus  higher,  ascending  into  the  abdominal  cavity ;  (6)  cervix  higher  in 
vagina ;  navel  no  longer  depressed  ;  (7)  fundus  uteri  two  fingers'  breadth 
above  pubes  at  the  end  of  the  fourth  month  ;  at  the  umbilicus  toward  the  end 
of  the  sixth  month;  (8)  cervix  more  softened  and  patulous;  (9)  fetal  active 
motion  (quickening)  experienced  toward  the  end  of  the  fourth  or  in  the  fifth 
month;  (10)  ballottement  detected,  becoming  more  distinct;  (11)  intermit- 
tent contractions  also  detected,  increasing  in  force ;  (12)  uterine  souffle  audible 
in  the  fourth  or  fifth  month;  (13)  fetal  heart-sounds  easily  detected,  usually 
first  in  the  fifth  month. 

Third  Period  of  Utero-gestation. — This  period  embraces  the  seventh,  eighth, 
and  ninth  months.  The  signs  and  symptoms  are — (1)  Menses  continue  absent; 
(2)  gastric  symptoms  slight  or  only  occasional ;  (3)  further  progressive  develop- 
ment of  the  mammary  signs,  colostrum  sometimes  present ;  (4)  uterus  continues 
to  rise  in  the  abdominal  cavity,  reaching  midway  between  the  navel  and  the  ensi- 


174  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

form  cartilage  at  the  end  of  the  seventh  month ;  reaching  the  ensiform  car- 
tilage in  the  first  two  weeks  of  the  ninth  mouth ;  after  which  period  it  grad- 
ually becomes  lower;  (5)  ballottement  continues  until  the  eighth  month,  when  it 
is  doubtful ;  it  is  absent  in  the  ninth  month ;  (6)  umbilicus  commencing  pro- 
gressively to  protrude;  (7)  vaginal  cervix  seemingly  shortened,  more  thick- 
ened, softened,  and  patulous,  getting  higher ;  (8)  fetal  movements  felt  or  seen 
after  the  sixth  month ;  (9)  in  last  two  weeks  the  fundus  uteri,  having  reached 
its  maximum  height  and  size,  begins  to  descend,  when  the  cervix  undergoes  an 
apparent  shortening.  Now  the  cervical  lips  become  thinner.  The  presenting 
part  of  the  fetus,  having  partially  entered  the  pelvic  inlet,  is  more  easily 
detected  by  vaginal  touch.  Pressure-symptoms  of  the  chest  and  the  stomach 
disappear,  though  edema  of  the  limbs  and  the  genitals  may  show  themselves. 

Relative  Value  of  the  Symptoms  and  Signs  of  Pregnancy  in  Point 
of  Diagnosis. — Very  properly  we  may  classify  all  the  symptoms  and  signs 
of  pregnancy  as  medical  evidence  of  the  presumptive,  the  probable,  and  the 
positive  kind.     They  naturally  rank  in  value  inversely  in  the  order  named. 

The  presumptive  evidences  of  pregnancy  are — (1)  Menstrual  suppression  ;  (2) 
morning  sickness  ;  (2)  irritable  bladder ;  (4)  mental  and  emotional  phenomena. 

The  probable  evidences  are — (1)  Mammary  changes;  (2)  the  bimanual 
signs;  (3)  abdominal  changes  in  size,  shape,  and  color;  (4)  changes  in  cer- 
vix uteri  in  size,  shape,  consistency,  and  color;  (5)  uterine  murmur;  (6) 
intermittent  contractions. 

The  positive  signs  are — (1)  Active  movements  of  the  fetus ;  (2)  passive 
movements  of  the  fetus  (ballottement) ;  (3)  fetal  heart-sounds. 

Differential  Diagnosis  of  Pregnancy. — Nothing  can  be  of  greater 
moment,  on  the  one  hand,  than  a  correct  diagnosis  of  pregnancy,  and,  on  the 
other,  of  the  many  conditions  simulating  pregnancy.  Only  the  inexperienced 
will  say  that  its  recognition  is 'an  easy  matter.  There  is  no  common  condi- 
tion of  the  female  human  body  so  often  overlooked  or  mistaken.  Not  only 
does  a  correct  estimate  of  the  actual  condition  concern  the  patient  and  her 
family  in  a  physical,  mental,  or  moral  sense,  but  the  professional  reputation 
of  the  physician  is  also  seriously  involved.  No  error  in  diagnosis  is  so  fatal 
to  the  interests  of  the  patient.  Almost  every  experienced  physician  could 
mention  instructive  and  amusing  mistakes  which  have  been  made.  The  legal 
and  social  relations  of  some  pregnancies  possess  a  deep  and  painful  interest ; 
therefore  let  no  opinion  be  expressed  in  any  case  until  a  reasonable  certainty 
can  be  arrived  at,     Time  may  be  needed  to  clear  up  all  doubts. 

As  pregnancy  implies  a  certain  variable  amount  of  abdominal  enlarge- 
ment after  the  fourth  month,  its  existence  must  necessarily  be  differen- 
tiated from  the  many  other  conditions,  physiological  and  morbid,  that  are 
attended  with  the  same  sign.  In  the  differential  diagnosis  not  much  diffi- 
culty need  exist  after  this  enlargement  is  fairly  well  advanced.  Most  mis- 
takes are  doubtless  made  when  the  gravid  uterus  is  still  within  the  pelvis; 
there  is  then  often  much  doubt.  There  will  first  be  considered  the  differential 
diagnosis  of  pregnancy  and  the  morbid  conditions  simulating  it  during  the 


DIAGNOSIS   OF  PREGNANCY.  lib 

first  three  months.  Just  here  comes  into  play  the  diagnostic  value  of  the 
sign  so  forcibly  elucidated  by  Hegar.  The  peculiar  shape  of  the  uterus  in 
the  second  and  third  months  of  pregnancy  (see  p.  166)  is  not  simulated  by 
anything  else.  While  in  a  measure  resembling  subinvolution  of  the  uterus, 
it  is  to  be  remembered  that  in  this  morbid  condition  there  is  an  organic  enlarge- 
ment uniform  in  all  directions.  In  chronic  metritis  attended  Avith  hyperemia, 
with  or  without  flexion,  the  uterus  is  not  jug-shaped,  and  the  elasticity  and 
compressibility  of  its  uterine  walls  are  absent.  Chronic  metritis  attended  with 
parenchymatous  hyperplasia  of  the  uterine  body,  shows  the  uterine  walls 
dense,  hard,  sensitive  to  touch,  not  elastic,  doughy,  or  boggy.  An  interstitial 
fibroid  in  either  uterine  wall  is  dense,  hard,  and  uneven.  Doubt  is  apt  to 
pertain  to  cases  of  pregnane}7  associated  with  chronic  retroversion,  but  then 
a  careful  analysis  of  the  presumptive  symptoms  will  always  be  helpful  in  dif- 
ferentiation. A  clear  study  of  the  physical  signs  of  the  cervix  and  the  corpus 
uteri  as  to  color,  size,  shape,  and  consistency  are  of  inestimable  value  in  the 
first  three  months.  A  search  for  Hegar's  and  the  other  bimanual  signs 
ought  never  to  be  neglected.  Pregnancy  may  be  concealed,  feigned,  and 
imagined.     These  possibilities  must  be  considered  and  be  cleared  up. 

When  pregnancy  has  created  material  abdominal  enlargement,  the  diagno- 
sis ought  to  be  differentiated  from  all  other  conditions  attended  by  the  same 
sign,  such  as  ascites,  ovarian  tumor,  uterine  fibroid,  distended  bladder,  tym- 
panites, pseudo-cyesis  (false  pregnancy),  enlarged  uterus  from  gas  (physo- 
metra)  or  from  water  (hydrometra),  retained  menses  (hematometra),  obesity, 
enlarged  abdominal  viscera,  malignant  disease,  etc.  In  differentiating  these  con- 
ditions the  three  positive  signs  of  pregnancy  should  always  be  borne  in  mind. 

In  ascites  fluctuation  is  most  distinct ;  the  resonant  note  on  percussion  is 
always  changed  in  location  according  to  the  position  of  the  patient.  Cardiac, 
hepatic,  or  renal  disease  can  usually  be  detected  as  a  causative  factor  of  the 
ascites,  and  the  symptoms  of  pregnancy  are  absent. 

In  ovarian  tumor  a  fluctuation  of  the  abdomen  is  also  present,  though  less 
distinct ;  the  abdominal  enlargement  has  come  on  more  slowly  and  has 
a  peculiar  shape:  Menstruation  is  ordinarily  present,  and  the  signs — intra- 
pelvic  and  abdominal — of  pregnancy  are  entirely  absent,  The  area  of  duluess 
and  tympanites  is  not  essentially  altered  by  posture.  As  pregnancy  and  an 
ovarian  tumor  quite  often  coexist,  a  constant  watch  ought  to  be  made  for  this 
possibility  in  every  case  of  an  abdominal  enlargement.  The  presence  of  two 
tumors  of  different  consistency  with  an  intervening  sulcus  is  quite  significant ; 
when  both  are  present,  the  uterus  itself  by  a  vaginal  examination  shows 
enlargement,  and  there  are  present  the  presumptive  symptoms  of  pregnancy, 
while  there  are  also  the  signs  of  an  ovarian  cyst. 

A  uterine  fibroid  creates  an  abdominal  enlargement  which  is  more  firm, 
hard,  and  dense  than  any  of  the  above-mentioned  conditions  •  it  is  nodular 
and  very  often  asymmetrical,  is  quite  slow  of  growth,  and  menstruation  is  not 
only  present,  but,  as  a  rule,  is  also  increased  in  quantity  and  lengthened  in 


17(3  AMERICAN    TEXT-BOOK    OF    OBSTETRICS 

duration.  While  the  uterine  murmur  may  be  very  well  marked,  there  are 
present  no  positive  signs  of  preguaucy. 

A  distended  bladder  is  of  comparatively  short  duration,  is  attended  with 
much  discomfort,  is  associated  with  dribbling  of  the  urine,  and  is  quickly 
relieved  by  the  use  of  a  catheter. 

Fecal  accumulation  is  dissipated  by  a  copius  rectal  enema  and  free  catharsis. 

Tympanitic  distention  of  the  abdomen  is  always  very  resonant  on  per- 
cussion, is  variable  in  size  on  different  days,  does  not  fluctuate,  and  quickly 
disappears  by  proper  treatment. 

Pseudo-cyesis,  or  false  pregnancy,  occurs  oftenest  toward  the  menopause, 
and  its  false  appearances  are  quickly  unmasked  by  the  administration  of  an 
anesthetic. 

Obesity  shows  the  abdominal  walls  soft,  doughy,  and  easily  palpated 
between  the  fingers  of  either  hand,  and  there  are  no  intrapelvic  signs  indicative 
of  pregnancy. 

Hydrometra  and  physometra  are  extremely  rare.  There  is  always  with 
them  an  absence  of  most  of  the  probable  and  all  the  positive  signs  of  preg- 
nancy. The  uterus  iu  both  diseases  enlarges  more  slowly,  and  never  to  the 
extent  of  an  advanced  pregnancy. 

Diagnosis  of  Extra-uterine  Pregnancy. — A  judicious  differential  diagnosis 
of  intra-uterine  pregnancy  implies  a  careful  consideration  of  the  possible  or 
probable  existence  of  extra-uterine  pregnancy.  This  is  especially  the  fact 
when  the  gravid  uterus  or  the  extra-uterine  sac  is  still  within  the  true  pelvis, 
for  if  the  diagnosis  is  the  best  guide  for  treatment,  now  is  the  time  of  all  others 
to  know  the  exact  condition  of  affairs.  The  following  symptoms  and  signs 
are  worthy  of  most  reliance  from  a  diagnostic  point  of  view.  When  extra- 
uterine pregnancy  exists,  there  are — ■ 

1.  The  general  and  reflex  'symptoms  of  pregnancy  ;  they  have  often  come 
on  after  an  uncertain  period  of  sterility.  Xausea  and  vomiting  appear 
aggravated  (Wiuckel). 

2.  Then  comes  a  disordered  menstruation,  especially  metrorrhagia,  accom- 
panied with  gushes  of  blood,  and  with  pelvic  pain  coincident  with  the  above 
symptoms  of  pregnancy.  Pains  are  often  very  severe,  with  marked  tender- 
ness within  the  pelvis.     Such  symptoms  are  highly  suggestive. 

3.  There  is  the  presence  of  a  pelvic  tumor  characterized  as  a  tense  cvst, 
sensitive  to  touch,  actively  pulsating.  This  tumor  has  a  steady  and  pro- 
gressive growth.  In  the  first  two  months  it  has  the  size  of  a  pigeon's 
egg ;  in  the  third  month  it  has  the  size  of  a  hen's  egg ;  in  the  fourth  month 
it  has  the  size  of  two  fists. 

4.  The  os  uteri  is  patulous;  the  uterus  is  displaced,  but  is  slightly  enlarged 
and  empty. 

5.  Symptoms  No.  2  may  be  absent  until  the  end  of  the  third  month,  when 
suddenly  they  become  severe,  with  spasmodic  pains,  followed  by  the  general 
symptoms  of  collapse. 

6.  Expulsion  of  the  decidua,  in  part  or  in  whole. 


DIAGNOSIS    OF  PREGNANCY.  177 

Xurnbers  1  and  2  are  presumptive  symptoms  of  extra-uterine  pregnancv; 
Xurnbers  3  and  4  are  probable  signs  of  extra-uterine  pregnancv ;  Numbers 
5  and  6  are  positive  signs  of  extra-uterine  pregnancv. 

Some  of  the  above-mentioned  symptoms  resemble  those  of  early  abortions. 
In  all  cases  with  the  history  of  a  supposed  abortion,  when  an  intrapelvic  mass 
is  then  or  afterward  felt,  there  should  be  suspicion  of  an  extra-uterine  preg- 
nancy. In  consideration  of  the  possibility  or  probability  of  extra-uterine 
pregnancy,  based  on  the  detection  of  a  lateral  extra-uterine  sac,  we  are  neces- 
sarily obliged  also  to  exclude  in  the  differentiation  a  small  ovarian  tumor,  an 
enlarged  ovary,  a  hydrosalpinx  or  a  pyosalpinx,  and  pelvic  exudates  (cellu- 
lar or  peritoneal).  A  distinct  sulcus  between  the  sac  or  the  tumor  and  the 
uterus  may  be  a  physical  sign  to  guide  in  the  diagnosis.  The  svmptoms  of  a 
severe  and  overwhelming  pain  are  quite  generally  manifested  bv  the  end  of  the 
third  month,  because  most  cases  are  tubal  in  some  form.  These  svmptoms 
are  not  noticed  when  the  extra-uterine  pregnancy  is  entirelv  abdominal.  The 
possibility  of  mistakes  in  diagnosis  is  to  be  considered  with  reference  to — (a) 
Retroflexion  of  the  gravid  uterus ;  (b)  pyosalpinx  with  amenorrhea,  or 
causing  abortion;  (c)  malignant  tumors  of  the  abdomen  with  ascites;  (d) 
normal  pregnancy  complicated  with  abdominal  tumors ;  (e)  coincident  intra- 
and  extra-uterine  pregnancy;  (/)  pregnancv  in  a  deformed  uterus. 

Diagnosis  of  Multiple  Pregnancy. — Suspicions  of  a  twin  pregnancv  are 
rarely  excited  ;  but  the  presence  of  multiple  pregnancv  mav  be  conjectured 
from  the  following  data :  (a)  Very  large  size  of  the  abdomen  ;  (6)  exaggera- 
tion of  the  results  of  a  gravid  uterus ;  (c)  irregularity  of  abdominal  enlarge- 
ment ;  (<f)  detection  by  palpation  of  the  abdominal  walls  of  two  fetal  heads 
and  other  parts  of  fetuses  ;  (e)  ballottement  imperfect  or  impossible ;  (J)  fetal 
movements  distinctively  felt  in  different  parts  of  the  abdomen  ;  (g)  recog- 
nition by  auscultation  of  two  fetal  heart-sounds,  not  synchronous  with  each 
other  and  heard  at  different  locations,  with  an  intervening  space  where  the 
heart-sounds  are  heard  feebly  or  not  at  all. 

Diagnosis  of  a  Prior  Pregnancy. — The  determination  of  this  question  may 
have  much  medico-legal  importance.  In  the  earlier  months  the  diagnosis  of 
any  previous  pregnancy  must  always  be  obscure,  even  if  search  has  been 
made  for  evidences  of  a  previous  pregnancy  within  a  few  days  after  the  expul- 
sion of  the  uterine  contents.  Of  course  we  would  expect  to  find  the  uterus 
more  or  less  enlarged,  some  local  hyperemia  of  it,  the  os  uteri  patulous,  and 
there  may  be  present  some  lochial  discharge.  But  these  distinctive  differences 
betweeu  the  uterus  which  has  suffered  an  early  abortion  within  the  first  three 
or  four  months  and  the  chronically-enlarged  uterus  menstruating  are  not  suf- 
ficient to  be  surely  reliable.  In  case  of  death  a  post-mortem  examination 
would  probably  throw  much  light  on  the  question  of  gestation.  In  an  aborted 
uterus  some  remains  of  the  placenta  or  of  the  decidua  might  be  detected,  the 
placental  site  would  be  imperfectly  involuted,  and  in  the  ovaries  the  corpus 
luteum  of  pregnancy  might  be  found. 

The   physical   evidences    of    a    previous   pregnaucy    are    most   distinctly 


178  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

marked  when  parturition  has  occurred  late  during  pregnancy  or  at  term. 
The  uterus  by  palpation  in  the  hypogastric  region  is  then  felt  much  larger ; 
the  lochial  discharge  is  more  characteristic ;  a  fatty  degeneration  can  be  de- 
tected in  the  uterine  walls  ;  the  placental  site  will  be  well  marked ;  the  vagina 
is  patulous  and  relaxed ;  the  corpus  luteum  of  pregnancy  is  quite  distinct. 
Should  the  cervix  uteri  or  the  perineum  have  been  lacerated  in  the  previous 
parturition,  they  will  be  observed  either  ununited  or  secondarily  healed.  The 
vulvar  fourchette  is  always  destroyed  after  the  first  delivery.  Very  often — 
quite  generally,  indeed — unmistakable  proof  of  a  previous  pregnancy  and 
delivery  is  noticed  by  vaginal  touch.  An  inspection  of  the  cervix  uteri  shows 
that  the  os  is  oval,  with  imperfectly-healed  rents.  A  careful  examination  after 
death  will  show  the  same  condition,  and  the  cervical  canal  will  be  found  less 
fusiform  and  more  patulous ;  the  uterus  is  enlarged  and  heavier,  the  corpo- 
real cavity  having  lost  its  clearly-defined  triangular  shape,  the  fundus  uteri 
being  no  longer  convex,  as  in  a  nullipara,  but  flat  or  concave. 

The  pelvic  floor  is  relaxed  in  multipara?,  the  vaginal  mucous  membrane 
is  smooth,  the  vulva  gapes,  and  some  degree  of  a  cystocele  or  rectocele  is 
almost  always  detected. 

All  general  appearances  of  recent  deliveries  are  very  uncertain  ;  there  are 
none  which  may  not  be  produced  by  other  conditions.  Some  women  look 
perfectly  well  after  a  delivery,  and  oue  unacquainted  with  the  clinical  history 
would  never  suspect  that  parturition  had  occurred.  Inspection  of  the  abdo- 
men is  more  to  be  depended  on.  A  soft  and  relaxed  abdominal  wall,  with  the 
skin  thrown  into  folds,  traversed  by  white  shiuirfg  lines  (lineae  albicantes) 
extending  from  the  groin  to  the  navel,  is  strong  probable  proof  of  recent 
delivery.  The  breasts  after  the  first  few  days  are  fuller,  are  tumid,  and  they 
contain  the  lacteal  secretion.  The  presence  of  colostrum-corpuscles  bespeaks 
a  recent  delivery.  The  nipples  show  the  characteristic  areolae.  The  breasts 
look  flabby,  sag  down,  and  are  ill  supported.  White  and  glistening  scars  of 
old  striae  may  be  seen  along  the  bases  of  these  glands. 

Chloasma  uterinum  usually  occurs  on  the  face  of  pregnant  women,  and 
lasts  for  many  years.  But  the  same  skin  affection  is  also  met  with  in  single 
women,  and  even  in  men.  It  is  due  to  physiological  and  pathological  changes 
in  the  uterus  and  to  various  disorders  of  the  menstrual  functions. 

Diagnosis  of  the  Life  or  the  Death  of  the  Fetus. — The  fetus  may  from 
some  cause,  maternal  or  fetal,  die  in  utero  before  its  time  of  viability.  Such 
a  death  generally  shows  itself  sooner  or  later  by  certain  maternal  symptoms. 
The  patient  has  a  feeling  of  languor  and  physical  depression,  with  impaired 
appetite ;  there  will  be  noticed  a  furred  tongue,  nausea,  vomiting,  and  a  pale 
and  sallow  color  of  the  patient.  Chilliness  with  some  fever  is  sometimes 
observed.  The  abdomen  does  not  progressively  enlarge ;  the  breasts  become 
flaccid  and  diminished  in  size;  and  a  fetid  discharge  from  the  vagina,  contain- 
ing exfoliated  epidermis,  is  a  certain  but  not  common  indication.  The  absence 
of  the  fetal  heart-sounds,  especially  if  once  heard,  and  the  cessation  of  active 
motion  of  the  child,  once  felt,  if  pregnancy  has  advanced  beyond  the  sixth 


DIAGNOSIS   OF  PREGNANCY.  179 

mouth,  are  positive  proofs.  Should  the  fetal  head  have  presented,  its  scalp 
becomes  soft  and  flabby;  the  cranial  bones  are  loose  aud  movable,  overlapping 
one  another.  The  lips  of  the  fetal  mouth  in  face  presentations  become  flabby 
and  motionless.  No  caput  succedaneum  can  form  in  delivery,  for  there  is  no 
fetal  circulation  to  assist  in  its  production.  Large  quantities  of  meconium  may 
be  discharged,  although  the  breech  does  not  present.  Should  the  breech  present, 
the  examining  finger  discovers  that  the  anal  sphincter  of  the  fetus  will  not 
spontaneously  contract.  The  umbilical  cord,  prolapsing  in  shoulder  or  other 
presentations,  is  cold,  flaccid,  and  pulseless,  contrary  to  its  warm,  full,  and 
pulsating  condition  during  fetal  life. 

The  rapidity  of  maternal  infection  from  retention  within  the  uterus  of 
a  dead  fetus  will  depend  upon  her  vital  resistance,  the  condition  of  her  general 
health,  and — the  most  important  factor — whether  or  not  the  membranes  have 
been  ruptured  and  atmospheric  air  has  entered  the  uterine  cavity.  As  the 
fetal  heart-sounds  are  the  most  valuable  and  positive  evidence  of  the  exist- 
ence of  pregnancy,  it  is  an  equally  valuable  proof  of  fetal  life.  Its  absence 
is  not  a  conclusive  test  of  the  death  of  the  fetus  if  pregnancy  unmistakably 
is  present.  Any  cessation  in  the  growth  within  the  abdomen  is  also  to  be 
determined  by  careful,  repeated  stethoscopic  examinations  and  successive 
measurements  of  the  abdomen  with  a  tape-measure.  Invariably  will  there 
be  a  steady  increase  in  the  size  of  the  abdomen  if  the  fetus  is  alive ;  no 
increase,  probably  a  slight  decrease,  if  it  is  dead. 

How  vital  it  is  to  be  aware  of  the  life  or  death  of  the  fetus  must  be  evi- 
dent when  we  consider  the  possibilities  and  probabilities  of  the  retention  in 
utero  of  a  dead  or  decomposing  fetus. 

2.  Duration  of  Pregnancy. 

Parturition  or  childbirth  means  the  end  of  pregnancy.  The  end  of  preg- 
nancy, or  the  time  of  expected  labor,  is  always  important  to  foretell,  not  only 
for  the  physician's  but  also  for  the  patient's  sake.  Cazeaux  has  given  expres- 
sion to  the  statement  that  conception  is  more  apt  to  follow  when  a  voluptuous 
sensation  or  a  general  erethism  occurs  during  or  following  coitus ;  but  this 
cannot  be  true.  Many  women  are  always  passive  in  coitus,  and  all  women  are 
entirely  passive  in  conception. 

The  normal  duration  of  pregnancy  is  nine  calendar  months  or  about  ten 
lunar  months.  To  be  more  exact,  its  duration  is  between  two  hundred  aud 
seventy  and  two  hundred  and  eighty  days,  from  the  first  day  of  the  last  oc- 
curring menstrual  period,  or  about  two  hundred  and  seventy-five  days,  calcu- 
lated from  its  cessation.  Various  methods  have  been  suggested  to  obtain  the 
time  of  the  expected  parturition  ;  the  most  reliable  of  these  methods  is  as  fol- 
lows :  Determine  the  exact  day  at  which  the  last  menstruation  appeared. 
Count  forward  nine  months,  or,  better,  count  backward  three  months,  aud  then 
add  seven  days.  Irrespective  of  the  time  of  the  year  from  which  this  count 
is  begun,  a  very  close  approximation,  from  two  hundred  and  seventy-eight 
to  two  hundred  and  eighty  days,  is  obtained.  This  is  the  rule ;  but  it  is  un- 
certain and  exceptions  are  not  uncommon.     Many  difficulties  are  experienced 


180  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

in  determining  the  date  of  the  expected  parturition.  As  most  pregnancies 
occur  in  married  women,  we  cannot  base  any  calculations  on  a  single  act  of 
coitus.  Even  if  there  has  been  but  one  coitus,  all  physiologists  admit  that 
there  is  a  variable  period  in  different  women,  and  in  the  same  woman  at  dif- 
ferent times,  between  insemination  and  the  fertilization  of  the  ovum. 

When  the  impossibility  of  ascertaining  the  precise  time  of  fertilization 
and  the  probable  variation  in  the  length  of  gestation  itself  are  considered, 
the  reasons  for  this  uncertainty  become  apparent.  Recognizing  with  His 
that  the  moment  of  fecundation  marks  the  beginning  of  pregnancy,  the  pos- 
sibility of  fixing  this  occurrence  becomes  of  great  interest.  The  uncertainty 
becomes  still  greater  owing  to  our  inadequate  knowledge  as  to  the  length  of 
time  during  which  the  sexual  elements,  the  ova  and  the  spermatozoa,  retain 
their  vitality  after  liberation  from  their  respective  sources. 

While  the  exact  time  during  which  the  matured  but  unfertilized  ovum 
retains  its  power  of  successfully  receiving  the  male  element  is  unknown,  the 
observations  conducted  on  lower  animals  render  it  probable  that  the  ovum  is 
capable  of  impregnation  at  any  time  during  its  sojourn  within  the  oviduct  and 
before  reaching  the  uterus,  or,  probably,  for  a  period  of  about  one  week  from 
its  escape  from  the  Graafian  follicle. 

The  remarkable  vitality  of  the  spermatozoa  even  under  far  less  favorable 
conditions — direct  observation  showing  that  these  elements  retain  their  move- 
ments for  over  nine  days  outside  the  body — renders  it  almost  certain  that  their 
powers  of  fertilization  are  maintained  for  a  long  time  after  they  are  deposited 
within  the  healthy  female  generative  tract ;  the  assumption  of  His,  Haus- 
rnann,  and  others  that  the  spermatoza  are  capable  of  fertilization  after  their 
sojourn  of  three  or  more  weeks  within  the  oviduct  is  well  founded. 

Consideration  of  these  facts  renders  apparent  the  impossibility  of  fixing 
with  certainty  the  beginning  of  pregnancy,  since  conception  may  result  from 
the  union  of  the  ovum  liberated  at  the  commencement  of  menstruation  with 
the  spermatozoa  introduced  toward  the  end  of  the  period ;  or  it  may  result,  as 
pointed  out  by  His,  from  the  meeting  of  the  male  elements  already  within  the 
oviduct  with  an  ovum  discharged  a  day  or  two  before  the  occurrence  of  the 
menstrual  phenomena.  The  possible  discrepancies  arising  from  these  causes 
have  been  represented  graphically  by  Marshall  as  follows : 

I.,  2,  3.  4,  5,  6,  7     .     .     .     .     .' 26,  27,  28,  II. 

in  which  I.  is  the  first  day  of  the  last  actually  occurring  menstrual  period, 
and  II.  is  the  first  day  of  the  first  omitted  period.  Should  pregnancy,  how- 
ever, occur  under  the  conditions  regarded  as  possible  by  His — that  is,  by  the 
fertilization  of  an  ovum  precociously  discharged  just  prior  to  the  first  omitted 
period,  a  discrepancy  of  over  three  weeks  would  appear  between  the  actual 
termination  of  pregnancy  and  the  estimated  date  of  labor,  when  calculated  in 
the  usual  manner  from  the  first  day  of  the  last  occurring  menstruation.  The 
general  consensus  of  opinion,  however,  regards  the  time  immediately  following  the 
menstrual  period  as  that  most  favorable  for  fertilization,  the  upper  third  of  the 
oviduct  being  probably  the  locality  where  fecundation  most  usually  takes  place. 
Should  impregnation  have  occurred  following  the  menstrual  period,  the 


DIAGNOSIS    OF   PREGNANCY.  181 

next  expected  period  will  almost  certainly  be  absent ;  but  if  it  has  taken  place 
within  a  few  days  before  an  expected  period,  the  expected  flow  may  not  physi- 
ologically be  suspended,  but  simply  be  diminished  in  quantity  or  be  short- 
ened in  duration.  The  prediction  of  the  date  of  labor  from  the  last  menstrua- 
tion is  likewise  very  unreliable  in  all  women  in  whom  its  previous  occurrences 
have  been  irregular  or  uncertain  in  time. 

Quickening,  as  a  rule,  is  noticed  by  the  female  in  the  fourth  month — about 
four  and  one-half  months — and  it  is  not  unusual  for  counts  to  be  made  from 
this  period.  But  as  quickening  (active  movements  of  the  child)  is  felt  at  un- 
certain times,  this  rule  has  been  found  to  be  very  fallacious.  At  a  certain  time 
it  proves  to  be  the  most  reliable  of  any  rule  for  adoption — namely,  when  men- 
struation has  physiologically  been  suspended  by  an  intercurrent  lactation. 
Then  there  is  no  last  menstrual  period  to  count  from,  and  we  have  but  to  add 
four  and  one-half  months  to  this  time  of  quickening  to  determine  the  approxi- 
mate time  of  the  expected  labor. 

The  prediction  of  the  date  of  labor  can  never  be  more  than  approximately 
accurate.  The  variation  of  a  few  days  either  way  is  the  rule ;  so  is  the  pro- 
longation of  pregnancy,  even  for  a  month  or  more,  by  no  means  very  rare. 
A  reasonable  certainty  of  the  date  of  parturition  may  be  predicted  if  the 
examinations  are  made  within  the  last  two  weeks  of  gestation,  after  the 
natural  shortening  of  the  cervix  uteri  has  commenced. 

It  is  no  wonder  that  the  duration  of  pregnancy  in  the  human  female  has 
been  such  a  fruitful  topic  for  discussion  among  obstetricians.  Not  only  the 
moral  character  of  a  woman,  but  also  the  legitimacy  and  the  hereditary  rights 
of  a  child,  may  depend  upon  a  fair  solution  of  this  question.  Is  it  possible 
for  a  women  to  give  birth  to  a  child  ten,  eleven,  or  twelve  months  after  the 
death  or  the  continued  absence  of  her  husband?  is  a  medico-legal  question 
concerning  which  the  obstetrician  may  be  called  upon  to  express  an  opinion. 
Experience  with  some  of  the  lower  animals  in  whom  the  date  of  a  single 
coitus  is  well  fixed,  and  the  records  made  by  numerous  distinguished  obstetric 
authorities,  make  such  exceptional  instances  as  reliably  creditable.  Most  of 
such  offspring  are  very  large  male  children. 

3.  Prolongation  op  Pregnancy. 

Sir  Chai'les  Clark  in  1816,  when  giving  his  evidence  in  the  famous  Gard- 
ner-Peerage case  before  the  House  of  Commons,  said  :  "  I  have  never  yet  seen 
a  single  instance  in  which  the  laws  of  nature  have  been  changed,  believing  the 
law  of  nature  to  be  that  parturition  should  take  place  forty  weeks  after  con- 
ception." Many  physicians  of  the  present  day  hold  that  the  law  of  nature 
is  quite  fixed  in  this  respect — that  human  pregnancy  never  exceeds  this  term. 
But  we  have  now  sufficient  evidence  to  show  that  human  pregnancy  is  not  so 
definitely  and  precisely  fixed  as  some  think.  The  duration  of  pregnancy  may 
be  shorter  or  longer  than  280  days. 

To  what  extent  may  pregnancy  be  prolonged,  and  what  are  the  evidences 
of  its  prolongation  ?  It  is  easy  to  understand  the  moral  and  legal  aspects  of 
this  important  question.     The  moral  character  of  the  female,  and  the  inherited 


182  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

rights  and  legitimacy  of  au  offspring  may  depend  on  a  fair  and  just  fixation  of 
its  paternity,  and  on  the  determination  of  the  possibility  of  the  prolongation 
of  human  pregnancy,  as  when  a  woman  gives  birth  to  a  child  ten,  eleven,  or 
twelve  months  after  the  death,  or  the  forced  absence,  of  the  husband.  Laws 
on  this  question  vary  in  different  countries.  In  France  legitimacy  cannot  be 
contested  until  300  days  have  elapsed  since  the  death  of  the  husband,  and  in 
Austria  and  Prussia  about  the  same  time  is  allowed.  In  England  and  in  the 
United  States  no  time  is  fixed. 

Numerous  cases  are  on  record  of  a  prolongation  of  pregnancy  to  336,  332, 
324,  and  319  days,  respectively,  after  the  last  menstruation.  Granting  that 
conception  in  these  cases  did  not  take  place  within  a  few  days  after  the  last 
menstruation,  as  is  the  rule,  but  was  postponed  to  just  before  the  first  missed 
period  of  that  function,  we  can  subtract  about  23  days  from  these  periods  of 
gestation,  and  will  then  have  313,  309,  301,  and  296  days,  each  exceeding  the 
ordinary  duration  of  pregnancy. 

Admitting  that  the  first  menstrual  cessation  was  due  to  some  abnormal 
cause — a  mere  possibility — we  will  still  have  a  prolonged  duration  of  preg- 
nancy. Hence  the  possibility  of  a  variation  of  a  conception  being  uncertain 
as  to  time  does  not  account  for  the  great  variation  in  gestation  so  often 
observed.  It  is  extremely  uncommon  in  healthy  young  women  for  a  men- 
strual period  to  be  skipped  for  one  time  only  without  there  being  some  notice- 
able change  in  the  bodily  health. 

Variations  in  the  duration  of  pregnancy  occur  in  cows,  in  which  there  have 
been  careful  records  of  a  single  coitus.  When  impregnation  occurs  in  the  human 
female  as  the  result  of  a  single  coitus,  the  date  of  which  is  accurately  recorded, 
as  among  single  women  or  among  married  women  whose  husbands  have  been 
absent  for  months,  possible  errors  of  the  date  of  conception  may  be  avoided. 
If,  then,  pregnancy  is  at  tinles  prolonged,  to  what  extent  is  there  any  pro- 
traction '?  Meigs,  Atlee,  and  Simpson  have  mentioned  instances  when  the 
duration  was  prolonged  to  almost  or  quite  a  year.  Dewees  records  a  case 
which  was  prolonged  to  ten  calendar  months.  Playfair,  Lusk,  and  Leishman 
mentioned  cases  of  considerable  prolongation.  Taylor  and  Beck  in  their  work 
on  Medical  Jurisprudence  record  numerous  instances  of  protracted  gestation. 

Other  physiological  functions  of  life,  such  as  dentition,  puberty,  or  men- 
struation, may  vary  as  to  the  time  of  occurrence.  Some  women  appear  to  go 
uniformly  beyond  the  usual  time  for  parturition.  The  degree  of  uterine  activity 
must  be  less  with  them.  More  frequently  the  sex  of  the  forthcoming  delayed 
child  is  male  rather  than  female.  We  are  forced,  then,  to  the  conclusion,  by 
a  study  of  the  analogy  of  other  functions  of  the  body,  by  observations  in  the 
lower  animals,  and  by  accurate  reliable  data,  from  women  in  particular,  to 
believe  that  pregnancy  may  be,  and  often  is,  prolonged.  Gestation  may  be 
lengthened,  parturition  may  be  delayed,  from  a  few  days  to  several  months. 

The  causes  which  conduce  to  labor — the  maturing  of  the  decidua  vera,  its 
preparatory  disintegration,  and  the  final  detachment  of  the  membrane  of  the 
ovum  from  the  uterine  lining — do  not  always  occur  at  the  same  time  or  with 
the  same  degree  of  activity ;  hence  gestation  may  be  prolonged. 


HYGIENE  AND   MANAGEMENT   OF  PREGNANCY.        183 

III.  HYGIENE  AND  MANAGEMENT  OF  PREGNANCY. 

Hygiene  of  Pregnancy.- — To  be  carried  safely  through  the  period  of  utero- 
gestation,  the  most  critical  time  of  her  life,  physiologically  speaking,  the  preg- 
nant woman  needs  special  care.  Because  pregnancy  is  a  physiological  con- 
dition, it  does  not  follow  that  the  patient  requires  no  care  until  parturition 
commences.  Every  pregnant  woman  needs  the  judicious  advice  of  an  intelli- 
gent obstetrician  as  to  the  mode  and  method  of  management  of  her  condi- 
tion. Little  or  no  medicine  is  usually  called  for,  but  certain  hygienic  rules 
ought  to  be  carefully  observed.  Particular  attention  is  to  be  given  her  in 
the  selection  of  diet,  exercise,  rest,  sleep,  clothing,  and  bathing.  Her  mental 
condition  is  to  be  watched  ;  her  attention  diverted.  The  condition  of  the 
breasts  calls  for  some  prophylactic  treatment. 

Diet. — Very  early  in  pregnancy  the  desire  for  food  is  diminished  and  cer- 
tain unusual  articles  of  food  may  be  craved.  Fair  quantities  of  food  are 
always  needed.  Respect  must  be  paid  to  her  morbid  longings  in  taste.  Thus 
the  time,  place,  and  social  association  in  partaking  of  food,  and  its  kind  and 
variety,  are  always  to  be  considered.  The  morning  sickness  is  thus  sometimes 
best  abated.  In  the  fourth  month  the  gastric  irritability  usually  spontaneously 
subsides,  the  appetite  reappears,  and  the  digestion  improves.  All  foods,  ani- 
mal and  vegetable,  that  are  reasonably  well  digested  and  nutritious  are  best 
suited  to  her  condition.  In  a  word,  the  diet  of  a  pregnant  woman  should  be 
plain,  simple,  easy  of  digestion,  highly  nutritious,  and  partaken  of  at  regular 
intervals.  A  moderate  supply  of  nitrogenous  food,  with  vegetables  and  fruits, 
is  called  for.  No  inflexible  rules  can  be  made  for  all  cases.  As  some  foods 
do  not  agree  equally  well  with  all  patients,  personal  likes  and  idiosyncrasies 
must  be  consulted.  A  generous  diet  improves  hematosis,  increases  functional 
activity,  augments  body-weight  and  body-heat,  imparts  tone  and  firmness  to 
the  blood-vessels  and  tissues,  and  diminishes  the  susceptibility  of  the  nervous 
system  to  pain  and  reflex  irritation.  That  the  diet  must  directly  influence 
the  growth  and  development  of  the  fetus  in  utero  is  reasonably  clear.  If 
any  restrictions  need  be  exercised  in  the  choice  of  foods,  it  is  that  animal 
foods  should  be  taken  in  moderation.  Kidney  excretion  should  not  be  over- 
taxed, the  stomach  never  overloaded,  and  good  digestion  secured.  Her 
special  nutritional  processes  may  be  improved  by  the  administration  of  the 
syrup  of  the  lacto-phosphate  of  lime,  three  times  a  day,  in  the  latter  months 
of  pregnancy. 

In  the  latter  part  of  pregnancy  the  gravid  uterus  has  risen  to  and  presses 
upon  the  stomach,  hence  food  has  to  be  taken  in  greater  moderation  and  at 
shorter  intervals.  A  milk  diet  is  at  times  especially  needed.  Albuminuria  is 
a  condition  calling  for  the  use  of  milk,  as  recommended  by  Tarnier.  Its 
absolute  use,  strictly  enforced,  gives  very  good  results  in  this  complication. 

Exercise. — Moderate  exercise  can  almost  always  be  well  borne.  Violent 
exercise  and  excessive  fatigue  are  invariably  to  be  avoided.  Extraordinary 
exercise,  such  as  riding  horseback  or  over  rough   roads,  dancing,  or  lifting 


184  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

heavy  weights,  is  injurious.  Long  journeys  by  water  or  by  land  should  be 
postponed  if  possible. 

Is  parturition  made  more  easy  by  unusual  physical  exercise?  Affirmatory 
opinions  have  been  entertained.  Doubtless,  women  whose  habits  have  accus- 
tomed them  to  considerable  physical  exercise  can,  all  things  being  equal, 
undergo  parturition  easily  and  quickly;  but  those  unaccustomed  to  any  special 
physical  exercise  should  undertake  only  what  can  comfortably  be  borne.  If 
active  exercise  is  not  well  borne,  then  passive  exercise  may  be  highly  bene- 
ficial. Riding  in  the  open  air  gives  the  pregnant  woman  the  necessary  fresh 
air  and  sunlight.  Crowded  and  ill-ventilated  rooms  are  to  be  avoided. 
While  moderate  exercise  is  needed  in  many  or  in  most  cases,  its  continuance 
is  objectionable  in  cases  where  the  normal  relaxation  of  the  pelvic  joints 
becomes  excessive.  The  pubic  joints,  most  often  affected,  are  so  relaxed  at 
times  that  locomotion  is  impeded  and  rest  is  demanded. 

Rest. — A  pregnant  woman  needs  abundance  of  sleep,  because  of  its  health- 
giving,  restoring  influence.  A  portion  of  each  day,  after  the  mid-day  meal, 
may  well  be  selected  for  the  assumption  of  the  recumbent  posture,  to  obtain 
for  an  hour  or  two  either  rest  or  sleep. 

Clothing. — Great  care  is  to  be  taken  that  the  clothing  is  so  adjusted  as  not 
to  compress  the  abdomen  and  the  chest.  While  the  quantity  and  the  quality 
of  the  clothing  are  to  be  determined  by  the  season  of  the  year,  the  garments 
placed  around  the  waist  are  to  be  as  light  as  practicable  consistent  with  com- 
fort. The  clothing  is  best  suspended  from  the  shoulders.  The  corset  and 
tight-fitting  skirts  are  injurious,  impeding  as  they  do  the  expansion  of  the 
growing  uterus  and  its  contents,  and  favoring  the  development  of  symptoms 
of  a  not  uncommon  complication  of  pregnancy — albuminuria  with  uremia. 
Multipara?  with  relaxed  abdominal  walls  often  experience  comfort  by  giving 
support  to  these  parts  with  an  abdominal  bandage,  thereby  maintaining  the 
uterus  in  a  more  normal  position,  wherein  there  is  better  accommodation  of  the 
fetus.     All  possible  pressure  of  the  pelvic  and  renal  veins  is  to  be  removed. 

Bathing  is  to  be  administered  to  the  body  at  the  usual  intervals  observed 
in  health — daily  in  warm  weather,  and  at  least  twice  a  week  in  cold  weather. 
The  baths  are  to  be  general,  with  an  abundance  of  water  and  soap.  The  tem- 
perature of  the  bath  may  be  either  warm  or  cool,  according  to  previous  habits 
and  to  the  season  of  the  year.  The  functional  activity  of  the  skin,  quite  often 
impeded  in  the  last  weeks  of  pregnancy,  should  be  maintained  carefully  by  the 
free  use  of  the  bath. 

Vaginal  injections  are  not  required  if  there  is  no  leucorrhea,  vaginal  or 
uterine.  If  an  injection  is  given  because  of  this  complication,  there  is  nothing 
better  than  a  saturated  solution  (one  quart)  of  boric  acid  given  with  a  fountain 
syringe  in  a  very  gentle  current, 

Sexual  intercourse  is  to  be  regulated  carefully,  for  very  often  it  is  found  to 
be  injurious  to  pregnant  women.  While  especially  enjoyed  by  some  pregnant 
women,  coitus  is  distasteful  to  most  women  at  this  period,  and  it  becomes  the 
source  of  much  pelvic  discomfort  to  not  a  few  ;  it  may  create  an  abortion. 
Even  uncivilized  nations  have  condemned  the  privilege  of  sexual  intercourse 


HYGIENE  AND   MANAGEMENT   OF  PREGNANCY.        185 

during  the  period  of  pregnancy,  and  have  visited  punishment  on  the  offender. 
During  the  first  few  mouths  of  pregnancy,  when  so  many  abortions  occur,  and 
toward  the  last  of  pregnancy,  it  is  best  for  the  husband  and  wife  to  occupy 
separate  beds. 

May  local  treatment  to  the  diseased  cervix  and  canal  be  carried  on  during 
pregnancy?  With  proper  precautions  and  due  care,  this  question  is  answered 
in  the  affirmative.  Most  of  the  accidents  causing  the  induction  of  abortion 
by  local  interference  have  arisen  from  a  neglect  to  investigate  and  deter- 
mine the  condition  of  the  body  of  the  uterus,  and  to  ascertain  whether  it  may 
have  been  gravid.  Preguanev  aggravates  chronic  cervical  endometritis  in  that 
it  increases  the  cervical  catarrh,  the  granular  degeneration,  the  secondary 
vaginitis,  and  the  vulvar  pruritus.  By  the  gentle  use  of  warm  vaginal  injec- 
tions of  a  uniform  temperature,  and  by  the  topical  use  of  astringents  and  emol- 
lients, and  in  rarer  cases  of  the  nitrate  of  silver  in  solution,  not  only  may  the 
patient  be  made  more  comfortable,  through  an  improvement  in  the  local  con- 
dition and  the  arrest  of  reflex  disorders,  such  as  nausea  aud  vomiting,  but  par- 
turition itself  may  also  be  made  easier. 

The  mental  condition  of  pregnancy  is  always  important  to  consider. 
Emotional  susceptibility  is  usually  somewhat  increased.  The  pregnant  woman, 
quite  excitable  and  irritable,  readily  responds  to  external  influences  by  which, 
in  the  non-gravid  condition,  she  would  not  be  influenced.  Sometimes  she  feels 
unusually  well,  is  intellectually  brightened  aud  more  active,  takes  greater 
interest  in  her  household  affairs,  aud  says  she  is  positively  happier.  At  other 
times  a  certain  despondency  creeps  over  her  mental  state;  she  is  unusually 
morose ;  there  is  observed  irritable  moodishuess  or  peevishness  beyond  the 
control  of  the  will ;  the  senses  of  sight,  hearing,  smell,  and  taste,  and  the  sen- 
sory or  motor  nerves,  are  frequently  perverted  without  any  structural  changes 
•in  the  nerves  concerned.  All  these  perversions  or  exaltations  of  function  are 
doubtless  directly  or  indirectly  attributable  to  the  quantitative  aud  qualitative 
changes  of  the  blood  from  pregnancy,  and  to  the  physical  changes  going  on  in 
the  sexual  organs,  creating  reflex  disorders.  Structural  alterations  in  the 
growing  fetus  may  be  effected,  modified,  or  perverted  by  psychical  influences. 
Certain  fetal  disorders  may  result  from  maternal  impressions.  Monstrosities 
do  at  times  so  occur. 

Physiologists  admit,  and  observations  prove,  that  the  maternal  emotions 
do  affect  the  development  of  the  exterior  of  the  fetus.  Likewise  may  the 
mental  development  be  altered  in  its  complex  and  delicate  organization. 
Idiocy  may  so  result.  The  mind  influences  and  modifies  the  body  in  ways 
unexplained. 

In  view  of  these  facts  the  wise  physician  should  aim  to  direct  the  mental 
condition  of  his  patient.  While  all  sudden  unpleasant  news,  frights,  aud 
physical  shocks  are  carefully  to  be  avoided,  those  circumstances  which  im- 
properly harass  the  pregnant  woman  are  to  be  dismissed.  Kind  assurances  are 
ever  helpful.  A  judicious  amount  of  amusement  is  not  to  be  forgotten.  The 
mind  is  to  be  occupied  pleasantly,  and  diverted  into  new,  pleasing,  surprising 
channels,  into  associations  agreeable  and  cheerful.     Around  the  patient  should 


186  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

be  thrown  a  gentle,  protective  care,  and  she  should  ever  be  treated  with 
considerate  kindness.  It  becomes  the  duty  of  the  husband  to  give  his  wife 
an  intelligent  co-operation  to  bear  her  burden. 

Management  of  Pregnancy. — It  becomes  the  duty  of  every  practitioner 
of  medicine  engaged  to  attend  a  woman  in  an  expected  parturition  not  only  to 
give  her  some  general  hygienic  directions  as  to  diet,  dress,  exercise,  and  the 
regulation  of  her  bowels  and  skin,  but  also  in  a  general  way  he  should  assume 
some  professional  care  of  her  throughout  her  pregnancy.  Many  disorders  and 
complications  are  apt  to  arise  during  this  period,  and  much  depends  upon 
prompt  and  well-directed  advice  in  their  judicious  management. 

First  of  all,  the  stomach  disorder  most  frequently  occurring  calls  for  some 
attention.  Reference  has  been  made  to  its  dietetic  management,  more  effi- 
cacious, it  may  be,  than  the  medicinal.  In  this  connection  the  writer  has 
realized  general  good  results  from  the  administration  for  a  time  of  koumiss. 
Failing  with  the  retention  of  the  food  on  the  stomach,  rectal  administration  of 
food  is  next  to  be  utilized.  For  the  physiological  nausea  and  vomiting  of 
pregnancy  the  writer  has  found  the  following  remedies  efficient :  Tincture  of 
nux  vomica,  weak  solutions  of  atropia,  sodium  bromid,  cocain,  and  electricity. 
Faradization  (secondary  current)  of  the  stomach  and  the  dorsal  spine,  and  gal- 
vanization of  the  central  sympathetic  are  worthy  of  a  more  extended  use  for 
this  affection  than  they  have  yet  received. 

Next,  the  alvine  evacuations  are  to  be  maintained  daily.  A  good  diet  and 
regularity  of  habits  show  their  good  results.  The  mineral  waters,  such  as 
Congress,  Hathorn,  the  sulpho-saline  waters,  or  a  solution  of  phosphate  of 
sodium  or  Carlsbad  salts  or  the  Seidlitz  powders,  are  indicated.  Purgation  is 
seldom  called  for.  The  best  laxative  remedies  are  aloein,  podophyllin,  and 
cascara  sagrada. 

Above  all,  it  is  important  that  careful  attention  be  given  to  the  renal  func- 
tion. Once  a  month  at  least,  during  the  latter  half  of  pregnancy,  should  the 
physical,  chemical,  and  microscopical  elements  of  the  urine  be  ascertained,  to 
detect  any  possible  alterations  in  its  quantity  and  quality.  Not  a  few  cases  of 
puerperal  eclampsia  from  uremia  may  thus  be  averted  or  be  modified  by 
a  supervision  of  the  kidney  excretion.  "  To  be  forewarned  is  to  be  fore- 
armed "  was  never  better  illustrated  than  just  here.  Albuminuria  is  present 
in  at  least  from  5  to  10  per  cent,  of  the  cases  of  pregnant  women  ;  some  claim 
that  the  proportion  is  larger. 

A  careful  examination  of  the  abdomen  may  very  properly  be  made  after 
fetal  viability.  The  external  examination  by  palpation,  together  with  an 
internal  vaginal  examination,  is  called  for  in  all  cases  toward  the  last  two 
weeks  of  pregnancy,  to  determine  not  only  the  fetal  viability  and  a  possible 
multiple  pregnancy,  but  also  to  ascertain  the  presentation  and  position  of  the 
fetus  in  utero,  the  existence  of  any  complications,  as  hydramnion,  and  to 
appreciate  the  cervical  condition  in  shape,  size,  and  patulousness,  in  order 
more  correctly  to  estimate  the  time  of  the  approach  of  the  expected  parturi- 
tion. The  pelvis  of  every  woman  should  be  examined  by  external  and 
internal  pelvimetry  in  the  seventh  or  eighth  month  of  pregnancy,  if  in  her  first 


HYGIENE  AND    MANAGEMENT   OF  PREGNANCY.         187 

pregnancy  or  if  she  has  had  any  special  difficulty  in  a  previous  parturition. 
At  the  time  of  this  examination  directions  may  be  given  as  to  the  preparation 
of  the  room,  the  bed,  the  garments,  and  as  to  obtaining  all  needed  articles. 

The  exact  methods  of  diagnosis  that  prevail  in  maternity  hospitals  ought 
also  to  exist  in  private  practice.  If  the  labor  promises  to  be  long,  difficult,  or 
very  painful  from  obstructions  of  any  kind,  the  obstetrician  ought  to  know  it  in 
advance,  that  he  may  elect  at  a  proper  time  before  parturition  whether  to  choose 
the  induction  of  a  premature  labor,  to  depend  on  the  use  of  the  forceps,  or  to 
resort  to  a  podalic  version,  a  symphysiotomy,  or  a  Cesarean  section.  How 
many  craniotomies  could  thus  be  avoided  and  maternal  deaths  prevented  ! 

The  mammary  glands  need  ample  room  for  their  development  to  prepare 
them  for  the  coming  function  of  lactation.  The  nipples,  especially  if  retracted, 
should  always  be  drawn  out  by  the  application  of  the  index  finger  and  the 
thumb  for  a  few  minutes  each  day  during  the  last  six  weeks  of  pregnancy. 
Exposure  of  the  glands  and  the  nipples  to  the  air  doubtless  tends  to  diminish 
their  tendency  to  become  sore  and  fissured.  Daily  ablutions  with  cold  water 
are  always  essential.  A  topical  application  of  the  following  as  a  prophylactic 
remedy  for  sore  and  fissured  nipples  is  to  be  recommended  when  it  is  thought 
desirable  to  use  an  astringent  application  : 

I^s.    Tannin,  oj  ; 

Glycerinse,  §ss ; 

Aquas  rosse,  3ss. — M. 
Sig.  Apply  daily  as  directed. 

As  no  two  pregnant  women  are  alike,  and  as  no  two  pregnancies  in  the 
same  woman  are  alike,  no  absolute  rule  can  be  framed  for  all.  The  expectant 
treatment  is  largely  called  for.  Discretionary  powers  are  necessarily  given 
the  physician  in  charge.  Only  general  principles  can  be  laid  down  for  guid- 
ance. Special  directions  are  called  for  when  there  are  special  disorders  and 
complications.  A  very  frequent  danger  is  that  an  abortion  or  a  premature 
delivery  may  be  precipitated  by  uterine  contractions.  Any  constitutional  dis- 
ease, especially  syphilis,  may  require  special  medication.  Doubtless  there  are 
remedies  which  often  favor  uterine  tonicity  and  become  prophylactic  against 
abortions.  Viburnum  pruuifolium,  aletris,  and  cimicifuga  doubtless  favor 
the  normal  completion  of  gestation.  In  all  cases  as  little  medicine  as  possible 
ought  to  be  given.  Pregnancy  is  a  purely  physiological  condition,  and  it  is 
best  managed  by  an  observance  of  the  hygienic  instructions. 

Are  there  any  means  at  our  disposal  to  make  labor  shorter  and  easier? 
Proper  hygienic  management  as  to  diet,  exercise,  clothing,  and  bathing  are 
always  beneficial  in  this  direction.  Few  medicinal  agents  are  needed.  Sto- 
machics are  useful  if  the  appetite  is  feeble.  There  is  no  better  nutritional 
tonic  in  pregnancy  than  the  syrup  of  the  lacto-phosphate  of  lime.  The  force 
of  uterine  contractions  may  be  enhanced  by  the  administration,  in  small  doses, 
of  quinine,  strychnia,  or  cimicifuga  for  weeks  before  delivery.  Doubtless 
these  agents  prepare  her  body  for  the  oncoming  painful  ordeal  and,  besides, 
they  will  favor  the  processes  of  puerperal  involution. 


IV.  THE  PATHOLOGY  OF  PREGNANCY/11 

The  remarkable  changes  occurring  in  the  organs  of  woman  throughout 
her  entire  body  as  gestation  advances  occasion  conditions  which  often 
transcend  the  bounds  of  health  and  become  states  of  disease.  As  these 
changes  are  most  pronounced  in  the  uterus  and  its  appendages,  it  will  be 
appropriate  to  consider  first  the  pathological  conditions  of  the  uterus  and  its 
appendages  induced  or  exaggerated  by  pregnancy.  It  will  then  be  proper  to 
study  the  general  derangements  which  the  condition  of  pregnancy  invites. 
Next  in  order  to  treat  of  the  influence  of  the  various  infectious  agents  upon 
the  pregnant  organism  ;  and  finally  the  surgical  injuries  and  processes  ob- 
served during  this  period. 

1.  Pathological  Conditions  of  the  Uterus  and  Appendages. 

AVhile  the  position  of  the  pregnant  uterus  is  subject  to  frequent  change, 
it  has  been  found  by  Ferguson1  and  others  to  be  rotated  to  the  right  in  from 
80  to  90  per  cent,  of  all  pregnant  women.  Great  distention  of  the  bladder 
may  temporarily  lessen  the  degree  of  rotation  upon  its  axis.  Occasionally 
this  dextro-torsion  becomes  excessive,  as  in  the  case  reported  by  Wenning,2 
in  which  the  uterus  at  six  months'  pregnancy  was  so  strongly  rotated  toward 
the  right  as  to  simulate  extra-uterine  pregnancy  upon  that  side.  The  left 
tube  was  greatly  enlarged. 

The  term  hypertrophy  best  describes  the  normal  condition  of  the  preg- 
nant uterus  in  the  various  phases  of  gestation.  Its  peritoneal  covering,  its 
interlacing  muscular  and  elastic  tissues,  and  its  glandular  lining  membrane, 
all  become  enlarged  by  the  production  of  new  elements  from  nuclei  already 
existing.  The  enormous  increase  in  area  and  in  blood-vessels  is  especially 
remarkable  in  the  pregnant  woman.  Although  the  deciduous  membranes 
represent  the  greatest  development  of  its  epithelial  elements,  still  the 
endometrium  shares  extensively  in  the  general  hypertrophy.  An  excellent 
description  of  the  physiological  and  pathological  changes  of  the  uterus 
during  jjregnancy  is  found  in  Gebhard's  Pathological  Anatomy  of  the 
Female  Sexual  Orc/anx.3J\  It  is  readily  seen  that  this  condition  of  plethora 
naturally  favors  the  rapid  development  of  any  neoplasm  previously  existing 
in  the  uterus,  especially  any  neoplasm  whose  elements  closely  resemble  normal 
uterine  structures.     Such  neoplasms  ai'e 

Myomata  of  the  uterus,  sometimes  termed  "  fibro-myomata  or  uterine 

*  The  superior  figures  (')  occurring  throughout  the  text  of  this  article  refer  to  the  bibli- 
ography given  in  the  Reference  List  on  page  362. 
t  Leipsic,  1S99,  S.  Hirzel. 
1SS 


THE  PATHOLOGY   OF  PREGNANCY.  189 

fibroids."  It  has  been  shown  by  Groom4  and  othei's  that,  although  myomata 
exist  frequently  among  childbearing  women,  they  do  not  always  attract  atten- 
tion during  pregnancy  and  are  often  undetected  at  labor.  Such  tumors  grow, 
however,  with  great  rapidity  during  pregnancy,  often  interfering  with  the 
circulation  in  the  lower  extremities.  Many  cases  in  which  early  pregnancy 
is  complicated  by  edema  of  the  legs,  and  in  which  abortion  occurs  at  four  or 
five  months,  accompanied  by  profuse  hemorrhage,  are  cases  of  fibroid  com- 
plicating pregnancy.  Their  bulk  causes  interference  with  the  functions  of  the 
bladder  and  the  rectum,  while  they  alter  the  position  of  the  uterus,  causing 
abnormal  presentations  of  the  fetus  and  prolapse  of  the  cord  at  labor.  Their 
encroachment  upon  the  uterine  muscle  interferes  with  its  normal  contraction 
and  retraction.  Hence  the  rhythmic  contractions  of  the  uterus  commonly 
existing  during  pregnancy  are  unusually  painful  and  sometimes  excessive  in 
strength.  The  substance  of  the  uterus  may  be  so  altered  that  rupture  of 
this  organ  may  occur,  as  in  a  case  described  by  Hogan,5  where  a  fibroid  preg- 
nant uterus  ruptured  spontaneously  at  about  the  fourth  month  of  gestation. 
When  rupture  does  not  take  place  spontaneous  reduction  of  a  displaced 
fibroid  uterus  sometimes  results  from  the  stimulus  of  growth  and  inter- 
mittent contractions  furnished  by  pregnancy.  Spontaneous  reduction  of  the 
uterus  is  frequently  followed  by  abortion,  as  pointed  out  by  Loviot.6  Although 
fibroid  tumors  of  the  uterus  are  often  supposed  to  prevent  conception,  cases 
are  on  record  where  sterility  persisting  for  some  years  in  such  patients  had 
been  replaced  by  pregnancy  so  late  as  forty-five  years  of  age.7  Pregnancy 
exerts  a  remarkable  influence  upon  fibroid  tumors  of  the  uterus,  not  only  in 
causing  their  rapid  growth,  but  also  in  frequently  bringing  about  a  condition 
of  well-marked  softening  and  fatty  degeneration.  This  pathological  state 
sometimes  decides  the  choice  of  a  method  of  treatment  in  these  cases. 

Among  the  most  interesting  and  important  of  the  recent  contributions  to 
the  study  of  fibroid  tumoi's  and  their  influence  upon  pregnancy  is  Hofmeier's 
article.8  Among  11,073  patients  he  found  550  who  had  fibroid  tumors  of 
the  Avomb,  a  percentage  of  4.3.  This  agrees  with  the  statistics  of  Engstroem, 
4.7,  and  Kleinwachter,  4.4.  Of  these  550  cases,  114  were  unmarried,  20.5 
per  cent.,  and  436  were  married,  73.5  per  cent.  Of  those  married,  117,  or 
26  per  cent.,  had  never  been  pregnant,  and  the  average  age  of  these  women 
was  40.5  years.  The  average  duration  of  marriage  in  these  cases  had  been 
fifteen  years.  Three  hundred  and  thirteen  of  those  married  had  been  preg- 
nant, and  on  an  average  3.6  pregnancies  had  occurred  to  each.  Of  those 
becoming  pregnant,  63,  or  22  per  cent.,  wTere  pregnant  once  only,  and  their 
average  age  was  42.7  years.  The  duration  of  this  secondary  sterility  was 
16.5  years.  Those  women  who  became  pregnant  more  than  once  had  on  an 
average  4.5  pregnancies  each.  As  regards  the  important  question  of  the 
influence  of  myomata  upon  conception,  Hofmeier  concludes  that  myoma  can 
be  in  some  instances  the  cause  of  sterility.  In  most  cases,  however,  the 
sterility  existed  and  from  other  causes  before  the  myomata  developed.  It  is 
seldom  that  sterility  can  be  assigned  to  a  myomatous  tumor  alone. 


190  AMERICAN   TEXT- BOOK   OF   OBSTETRICS. 

During  pregnancy  myomata  occasioned  complications  in  15  out  of  223 
cases.  In  many  of  these  the  pregnancy  was  not  allowed  to  go  on  to  labor, 
but  hysterectomy  was  performed  when  viability  was  fully  established.  Hof- 
meier  did  not  find  in  his  observations  a  tendency  to  complications  in  the 
third  stage  of  labor  in  women  having  myomatous  tumors  which  many  have 
described.  Hemorrhage  at  the  separation  of  the  placenta  was  infrequent  in 
his  observation.  The  general  result  of  his  studies  goes  to  show  that  fibroids 
are  rarely  the  exclusive  cause  of  sterility,  and  that  pregnancy  and  labor  may 
go  on  without  dangerous  complications  in  these  cases. 

The  treatment  of  pregnancy  complicated  by  fibroid  tumors,  when  interfer- 
ence is  necessary,  is  by  operative  procedure.  Submucous  tumors,  if  they 
become  pedunculated  and  distend  the  lower  uterine  segment,  frequently  pre- 
sent before  the  fetal  head,  and,  exciting  premature  labor,  may  be  removed 
by  the  obstetrician  in  advance  of  the  child.  Intramural  tumors  require  no 
treatment  during  pregnancy  unless  the  results  of  their  pressure  upon  impor- 
tant viscera  oblige  the  obstetrician  to  perform  hysterectomy.  Subserous 
fibroids  in  the  pregnant  patient  may  often  be  removed  without  terminating  the 
pregnancy,  as  in  cases  reported  by  Frommel9  and  others.  Should  extensive 
fibroid  changes  in  the  uterus  occur,  complicating  pregnancy,  this  condition 
should  not  be  allowed  to  go  on  to  term,  but  hysterectomy  should  promptly 
be  performed. 

Routier10  reports  a  successful  myomectomy  during  pregnancy,  and  has 
collected,  with  his  own,  fifteen  cases  in  which  the  operation  was  performed, 
ten  of  which  recovered.  Strauch  "  also  reports  the  successful  removal  of  a 
fibroid  as  large  as  a  goose  egg  from  a  pregnant  uterus  by  abdominal  section. 
Phillips12  gathered  reports  of  282  cases  of  fibroids  complicating  pregnancy. 
His  statistics  indicate  a  high  mortality  from  radical  procedures.  Pozzi,13 
from  his  collection  of  these  £ases  and  his  personal  experience  with  them, 
considers  simple  myomectomy  the  preferable  procedure  in  suitable  cases. 

Further  experience  in  hysterectomy,  however,  has  led  to  an  extension  of 
the  operation  of  myomectomy,  and  in  some  instances  surprising  results  have 
been  obtained  in  the  preservation  of  the  uterus.  Ohlshausen14  reports  a 
remarkable  instance  of  the  success  attained  in  removing  a  large  fibroid,  pre- 
serving the  uterus.  The  permanent  results  of  operations  for  fibroids  are 
given  in  detail  by  Burckhard,15  showing  operative  treatment  to  be  in  the 
main  successful.  Kelly16  urges  the  value  of  myomectomy,  reporting  97 
operations,  many  of  them  myomectomies,  with  four  deaths.  Edebohls v 
reports  the  removal  of  three  myomata  extensively  calcified,  with  the  preser- 
vation of  the  uterus.  Robb 1S  describes  the  conservative  treatment  of  the 
myomatous  uterus.  The  occurrence  of  spontaneous  abortion  sometimes  ne- 
cessitates immediate  operation  in  cases  of  pregnancy  complicated  by  fibroid 
tumors  ;  thus,  Bourcart 19  reports  the  case  of  a  pregnant  patient,  whose  gesta- 
tion was  complicated  by  myoma  of  the  uterus  and  by  excessive  torsion  of 
the  uterus  and  its  appendages.  Spontaneous  abortion  was  followed  by  chill 
and  fever.     Taking  advantage  of  a  fall  in  the  temperature,  Bourcart  per- 


THE   PATHOLOGY   OF  PREGNANCY.  191 

formed  hysterectomy.  The  result  was  successful.  Attention  has  also  been 
called  by  Hofmeier20  to  the  influence  which  myomata  exert  upon  pregnancy 
in  causing  abortion.  He  cites  from  the  records  of  others  796  cases  of  preg- 
nancy with  this  complication,  and  found  that  abortion  occurred  in  6.9  per 
cent,  of  the  cases.  He  naturally  concludes  that  the  majority  of  patients  who 
suffer  from  myomata  during  pregnancy  pass  through  gestation  but  slightly 
influenced  by  the  uterine  tumor. 

Ott21  reports  a  case  of  pregnancy  nearly  at  term  complicated  by  fibro- 
myoma  of  the  uterus  with  bronchitis.  Amputation  of  the  uterus  was  per- 
formed, the  stump  was  covered  with  peritoneum  and  dropped.  The  patient 
and  her  child  made  a  good  recovery.  Gordon 22  reports  a  successful  myomec- 
tomy by  which  a  fibroid  was  removed  from  the  anterior  wall  of  the  pregnant 
uterus ;  although  the  uterine  wall  was  left  thin  and  vascular,  hemorrhage 
was  controlled  by  stitching  the  peritoneum  and  the  base  of  the  wound  with 
fine  catgut.  Recovery  was  rapid  and  the  pregnancy  uninterrupted.  Stave- 
ley  M  collected  a  considerable  number  of  fibroid  tumors  complicating  preg- 
nancy, and  he  adds,  from  the  records  of  the  Johns  Hopkins  Hospital,  two 
cases  in  which  myomectomy  was  performed  successfully  during  pregnancy 
without  interrupting  gestation. 

Staveley's  tables  embraced  33  cases  with  a  maternal  mortality  of  24.25 
per  cent.  Statistics  show  that  in  late  years  myomectomy  for  this  condition 
is  more  successful  than  before  antiseptic  surgery  attained  its  present  perfec- 
tion in  technic.  During  the  last  eight  years  the  mortality-rate  of  myo- 
mectomy in  these  cases  has  fallen  to  11.75  per  cent. 

Cancer  of  the  uterus  during  pregnancy  increases  with  great  rapidity 
during  the  pregnant  state,  and  with  even  greater  vigor  during  the  puerperal 
condition.  When  pregnancv  has  not  advanced  beyond  the  fourth  month 
Van  der  Veer24  and  others  practise  vaginal  extirpation  of  the  uterus. 
Fritsch  M  reports  cancer  of  the  uterus  at  full  term  treated  by  rapid  dilata- 
tion of  the  cervix  by  means  of  deep  incisions  and  delivery  with  forceps. 
Vaginal  hysterectomy  was  done  immediately  after  delivery.  The  patient 
made  a  good  recovery.  Mittermaier2"  reports  two  cases  of  cancer  of  the 
uterus  complicated  by  pregnancy  successfully  treated  in  the  same  manner. 
At  seven  months'  gestation  Fehling2'  opened  the  abdomen  and  extracted 
the  fetus  and  placenta.  Hysterectomy  was  then  performed,  the  cavity  of 
the  cervix  being  seared  with  a  Paquelin  cautery.  Flaps  of  peritoneum  were 
closed  over  the  stump.  The  cervix  and  stump  of  the  uterus  were  then 
removed  through  the  vagina.     The  mother  made  a  good  recovery. 

Fehling28  gives  the  report  of  five  cases  of  cancer  of  the  cervix  compli- 
cating pregnancy  and  occurring  among  three  thousand  pregnant  patients. 
He  practised  removal  of  the  cancerous  uterus  either  by  vaginal  section  only 
or  by  vaginal  and  abdominal  section  combined.  Reekmann29  reports  the 
case  of  a  multipara,  six  months  advanced,  who  had  cancer  of  the  cervix.  The 
cervix  was  first  curetted  and  cauterized,  the  broad  ligaments  were  ligated 
with  catgut,  the  uterus  was  drawn  down,  the  cervix  incised  so  as  to  split 


192  AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 

the  uterus,  the  womb  was  then  emptied,  and  the  uterus  removed  in  the  usual 
manner.  As  regards  the  method  of  operating,  Ohlshausen30  states  the 
grounds  upon  which  the  choice  of  operation  depends,  and  shows  that  up  to 
the  time  of  writing  40  per  cent,  of  all  cases  of  cancer  of  the  uterus  had  been 
considered  suitable  for  vaginal  extirpation.  Baeckner,31  from  a  study  of  705 
cases  of  cancer  of  the  uterus  at  various  periods  of  life,  urges  the  importance 
of  total  extirpation.  Beckmann32  describes  two  cases  of  cancer  of  the  cervix 
complicating  pregnancy.  He  draws  attention  to  the  fact  that  cancer  does 
not  predispose  to  sterility  nor  does  it  tend  to  interrupt  pregnancy.  Gesta- 
tion is  often  prolonged. 

In  cases  where  carcinoma  attacks  the  cervix  the  prognosis  is  most  un- 
favorable. If  delay  is  practised,  the  tissues  surrounding  the  cervix  soon 
become  infiltrated  and  delivery  by  abdominal  section,  should  life  persist  to 
full  term  of  pregnancy,  is  the  only  alternative.  The  fact  that  carcinoma 
grows  with  greatest  rapidity  during  the  puerperal  condition  obliges  the  ob- 
stetrician, whenever  possible,  to  perform  complete  extirpation  of  the  uterus, 
either  at  the  time  when  the  fetus  is  delivered  or  as  soon  as  possible  there- 
after. The  danger  of  septic  infection  following  Cesarean  section  is  so  great 
that  the  majority  of  operators  prefer  hysterectomy  or  total  extirpation. 
Stacker33  performed  hysterectomy  at  the  sixth  month  of  gestation  for  cancer 
of  the  uterus  by  celiotomy,  constricting  the  cervix  with  an  elastic  tube  and 
removing  a  dead  fetus,  amputating  the  uterus,  closing  the  stump,  and  then 
removing  the  stump  by  vaginal  hysterectomy.  The  patient  had  but  little 
hemorrhage  and  made  a  good  recovery.  Coe34  contributes  an  interesting 
and  instructive  summary  of  the  status  of  operative  work  for  this  condition. 
Hernandez30  would  operate  by  removing  the  uterus  entirely  through  abdom- 
inal incision,  ligating  and  cutting  the  broad  ligaments,  then  opening  the  cul- 
de-sac  and  removing  the  wemb.  The  suture  threads  are  long,  tied  together 
and  drawn  down  into  the  vagina,  and  the  peritoneum  is  closed  from  above 
by  a  continuous  suture.  A  packing  of  iodoform  gauze  is  introduced.  Borr- 
man36  describes  a  case  of  sarcoma  of  the  cervix  with  metastases  in  both 
ovaries,  accompanying  pregnancy  and  terminating  with  abortion  at  the 
fourth  month.  The  type  of  malignant  growth  in  this  case  is  said  to  have 
been  wandering-cell  sarcoma,  and  the  question  naturally  arises,  "  Was  not 
this  a  case  of  deciduoma  malignum?" 

Cancer  occasionally  involves  the  uterine  tissue  so  extensively  as  to  result 
in  rupture  of  the  uterus.  This  extensive  involvement  occurs  in  cases  where 
pregnancy  supervenes  upon  the  existence  of  the  cancerous  condition.  The 
great  stimulus  which  pregnancy  causes  in  malignant  growths  results  in  the 
rapid  dissemination  of  malignant  tissues,  which  gradually  destroy  the  elas- 
ticity and  the  resisting  power  of  the  muscular  layers  of  the  womb.  Rupture 
occurs  in  these  cases  during  abortion  or  during  labor  at  term.  The  prog- 
nosis is  exceedingly  grave,  for,  even  should  the  patient  rally  immediately 
from  the  rupture,  the  malignant  growth  must  sooner  or  later  end  her  life. 

Auvard37  reports  the  case  of  a  patient  in  her  eleventh  pregnancy  who 


THE   PATHOLOGY   OF  PREGNANCY.  193 

had  uterine  cancer  for  two  years.  Labor  was  exceedingly  slow,  the  pains 
being  very  weak  but  persistent.  When  partial  dilatation  was  present  the 
os  was  incised  in  several  directions,  and  the  fetus  was  found  in  breech  pres- 
entation. Extraction  by  the  feet  was  performed,  and  persistent  hemor- 
rhage ensued.  On  examination  the  uterus  was  found  ruptured  transversely 
at  the  upper  side  of  the  lower  uterine  segment.  The  patient  succumbed  to 
shock.    ' 

Cancerous  infiltration  of  the  cervix  often  necessitates  multiple  incisions 
in  any  manipulation  during  pregnancy  or  at  labor.  Von  Herff M  illustrates 
the  value  of  free  incisions  in  cancerous  cases.  Cesarean  section  had  been 
decided  upon,  but  as  a  last  resort  multiple  incisions  were  freely  made,  and 
they  proved  efficacious.  Early  pregnancy  complicated  by  uterine  cancer 
invariably  demands  total  extirpation,  from  which  even  unfavorable  cases 
recover,  and  the  operation  has  prolonged  life,  as  illustrated  by  Moller.39  In 
his  patient  the  cancerous  uterus  was  extirpated  with  great  difficulty  by 
reason  of  the  infiltration  of  the  surrounding  tissue.  A  rent  was  left  in  the 
peritoneal  cavity  through  which  a  loop  of  intestine  protruded.  Notwith- 
standing these  remarkable  features  the  patient  made  a  good  recovery,  and 
some  time  after  the  operation  was  comparatively  free  from  cancer.  Sutugin 
reports  two  cases  of  amputation  of  the  uterus  at  term  for  cancer,  in  each  of 
which  the  life  of  the  child  was  saved.  Taylor,  of  Japan,40  records  a  very 
unfavorable  case  of  cancer  in  which  vaginal  extirpation  was  performed  with 
great  difficulty.     A  favorable  result  followed. 

In  cases  where  the  cervix  only  is  involved  diseased  tissues  should  at  once 
be  removed  by  the  knife  and  cautery,  with  the  hope  that  the  progress  of  the 
disorder  may  be  checked  temporarily  while  the  pregnancy  advances,  thus 
affording  the  child  a  better  opportunity  for  life.  In  carcinoma  of  the  preg- 
nant uterus  complete  extirpation  is  the  only  treatment  that  promises  a 
favorable  result.  If  the  patient  is  seen  for  the  first  time  in  pregnancy 
advanced  beyond  the  fourth  month,  delay  may  be  advised  in  the  interests  of 
the  child  so  long  as  the  tissues  about  the  uterus  do  not  become  involved. 
Under  the  improved  methods  now  followed  in  performing  total  extir- 
pation the  prognosis  for  the  mother  is  no  longer  desperate,  a  fair  chance 
for  recovery  from  the  operation  and  the  prolongation  of  life  being  thus 
given  her.41 

A  more  conservative  view  is  taken  by  Ohlshausen  a  of  the  ultimate  results 
of  operation  for  cancer  complicating  pregnancy.  He  urges  vaginal  extir- 
pation in  early  pregnancy,  and  removes  the  uterus  unopened  if  possible. 
He  quotes  twenty-five  cases  of  hysterectomy  of  the  pregnant  carcinomatous 
uterus  without  a  death.  He  does  not  believe  in  waiting  for  involution,  and  does 
not  consider  the  results  of  supravaginal  amputation  and  removal  of  the  cer- 
vix through  the  vagina  as  good  as  those  of  vaginal  extirpation.  He  would 
absolutely  decline  to  postpone  the  radical  operation  until  the  child  is  viable. 
If  called  to  a  case  of  cancer  complicating  pregnancy  at  viability,  he  would 
remove  the  child  through  the  abdomen,  incising  the  uterus  as  far  away  from 


194  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

the  cancerous  tissue  as  possible,  and  then  extirpating  the  uterus  through  the 
vagina.  While  he  admits  the  possibility  of  a  successful  operation,  he  believes 
that  the  malignant  growth  returns  in  most  cases.  He  considers  a  cure  of 
three  months'  duration  to  be  extraordinarily  successful.  It  is  an  interesting 
and  somewhat  extraordinary  fact  that  conception  may  follow  partial  opera- 
tion upon  the  pregnant  uterus.  Leinziger 43  adds  an  additional  case  to  seven 
already  published  in  which  conception  has  occurred  after  operations  for 
cancer  of  the  uterus.  His  patient  was  aged  forty-one,  and  was  curetted  for 
an  inoperable  cancer.  One  year  later  she  returned  with  a  recurrence  of  the 
enlarged  uterus.  She  was  again  curetted.  Soon  after  she  gave  birth  to  a 
growth  and  a  macerated  fetus,  and  finally  died  of  sepsis.  Pregnancy  had 
been  mistaken  for  hydrometra. 

It  is  interesting  in  this  connection  to  question  the  ultimate  results  of  the 
treatment  of  cancer  of  the  uterus.  In  an  extensive  paper  upon  this  subject 
Winter44  reviews  the  results  of  the  work  done  in  some  of  the  largest  clinics 
of  Europe,  in  which  various  methods  of  operation  have  been  undertaken. 
Taking  a  period  of  eight  years  from  the  time  of  operation,  he  finds  that  in 
cases  treated  by  vaginal  extirpation  of  the  uterus  for  cancer  10  per  cent,  of 
the  patients  have  been  practically  cured.  In  the  most  recent  cases  an  ap- 
pai*ent  cure  rises  to  15  and  20  per  cent.  The  mortality  of  operations  per- 
formed by  the  use  of  forceps  in  330  cases  was  7.5  per  cent. 

In  epithelioma  of  the  cervix  complicating  pregnancy  Edis45  reports  a 
case  in  which  an  epitheliomatous  mass  was  found  nearly  involving  the  whole 
cervix  and  extending  down  upon  the  posterior  vaginal  wall,  rendering  the 
passage  of  the  fetal  head  impossible.  The  child  was  delivered  by  Cesarean 
section,  and  seven  months  after  the  operation  the  epithelioma  had  made  but 
little  progress.  Sinclair46  describes  a  very  interesting  case  of  epithelioma  of 
the  cervix  in  a  pregnant  patient,  which  was  not  diagnosticated  in  the  early 
stages,  although  the  patient  was  in  the  hospital.  When  first  examined  the 
ulceration  was  so  shallow  that  it  was  hoped  that  the  disease  could  be  entirely 
removed.  As  a  preliminary  to  operation  the  uterus  was  emptied,  after  which 
the  patient  felt  so  much  improved  that  she  refused  further  treatment.  She 
finally  returned  and  applied  for  treatment ;  ulceration  had  become  extensive 
and  the  tissues  about  the  uterus  were  involved.  After  operation  the  patient 
remained  for  some  time  in  good  health,  but  finally  died  of  a  return  of  the 
disease.  There  was  every  reason  to  believe  that  cure  could  have  been 
obtained  had  the  patient  consented  to  early  operation. 

Attention  has  long  been  called  to  the  importance  of  the  fetal  appendages 
as  furnishing  a  starting-point  for  malignant  growth  of  the  uterus.  Stroga- 
nowa47  describes  a  case  observed  in  the  St.  Petersburg  clinic  where  the  devel- 
opment of  a  malignant  decidual  growth  could  be  distinctly  traced  in  the 
villi  of  retained  chorion  and  placenta.  The  specimen  was  remarkable  for 
the  intense  development  of  free  nuclei  and  cells.  Audebert  and  Sabrazes48 
report  from  the  clinic  at  Bordeaux  the  case  of  a  patient  who  aborted  at  three 
months.     The  placenta  was  retained  six  months  longer,  but  was  spontane- 


THE  PATHOLOGY   OF  PREGNANCY.  195 

ously  expelled  at  the  normal  termination  of  gestation.  Septic  infection  did 
not  occur.  On  examination  the  placenta  had  acted  as  a  malignant  growth, 
and  the  cells  of  the  placenta  had  developed  with  extraordinary  vigor. 

The  decidual  lining  of  the  uterus  may  occasionally  become  the  seat  of 
malignant  disease,  as  observed  by  Sanger  and  Chiari.49  This  form  of  cancer 
is  described  by  these  writers  as  a  true  sarcoma  of  the  decidua.  Its  symptoms 
are  foul  discharge  and  hemorrhage  persisting  after  labor,  and  its  fatal  termi- 
nation usually  occurs  within  six  or  seven  months  after  delivery.  Metastatic 
deposits  are  not  uncommon,  the  cells  of  which  bear  the  characteristics  of 
decidual  cells.  There  is  an  innocuous  form  of  this  growth,  also  described  by 
Sanger,50  that  is  not  to  be  mistaken  for  decidua  remaining  adherent  after  a 
former  pregnancy. 

It  is  not  within  the  province  of  an  article  not  devoted  to  pathology  to 
reproduce  the  voluminous  data  upon  the  subject  of  syncytioma  malignum, 
deciduoma  malignum,  or  chorio-epithelioma  of  the  uterus.  Whatever  differ- 
ences of  opinion  there  may  be  regarding  the  method  of  growth  which  this 
form  of  malignant  disease  shows,  its  signs  and  symptoms  are  sufficiently 
known  to  make  a  diagnosis  possible  in  most  cases,  and  to  give  clear  indica- 
tions for  treatment.  Clinically  speaking,  this  disease  may  be  suspected 
when  some  complication  occurs  which  prevents  the  pregnancy  from  going 
to  full  term  and  interferes  with  the  complete  discharge  of  the  embryo  or 
fetus  and  its  appendages.  It  is  often  associated  with  what  have  been 
termed  moles  or  blighted  ova.  The  history  is  often  like  that  given  by 
Peharn.51  His  patient,  aged  twenty-five,  had  an  abortion  with  considerable 
hemorrhage.  A  small  portion  of  retained  tissue  was  removed  from  the 
anterior  wall  of  the  uterus  without  much  difficulty.  On  microscopic  exami- 
nation an  epithelioma  of  the  chorion  was  diagnosticated,  and  the  uterus, 
tubes,  and  ovaries  were  removed  by  vaginal  extirpation.  The  patient  made 
a  rapid  recovery.  In  less  than  a  month  she  suffered  from  profuse  bleed- 
ing from  a  small  tumor  in  the  anterior  wall  of  the  vagina,  and  a  few  days 
later  she  expectorated  blood,  and  evidence  of  profound  involvement  of  the 
lungs  was  present.  Anders52  reports  two  cases,  in  one  of  which  the  disease 
had  considerably  enlarged  the  uterus  and  had  attacked  the  walls  of  the 
vagina.  The  uterus  was  curetted  and  extirpation  of  the  vaginal  tumors  was 
undertaken.  The  patient  perished  from  septic  infection.  In  his  second 
case  the  growth  had  opened  the  pelvic  peritoneum  behind  the  uterus  in  a 
patient  aged  twenty-five.  Nothing  could  be  done  to  check  the  hemor- 
rhage but  to  tampon  the  vagina  and  cervix.  Krebs 53  reports  the  case  of  a 
patient,  aged  twenty-three,  who  had  a  small  placental  polyp  removed  from 
the  uterus,  following  what  was  apparently  a  normal  labor.  She  unfortu- 
nately became  pregnant  soon  after  the  removal  of  the  polyp,  and  suffered 
from  hemorrhage,  chills,  and  fever.  Her  condition  was  such  that  operation 
was  impossible,  and  she  speedily  perished  from  the  disease.  He  also  reports 
the  case  of  a  patient  from  whom  he  removed  a  mole,  thoroughly  emptying  the 
uterus  and  washing  it  out.     This  patient  apparently  recovered  and  passed 


196  AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 

from  observation.  Examination  of  the  tumor  showed  that  it  was  begin- 
ning to  take  upon  itself  a  malignant  character.  An  interesting  case  of 
hydatid  mole  followed  by  malignant  development  is  reported  by  Solowij  and 
Krzyszkowski.54  The  patient  was  delivered  of  an  hydatid  mole  and  perished 
from  septic  infection.  At  autopsy,  chorio-epithelioma  was  diagnosticated 
with  metastases  in  the  lungs  and  also  in  the  larynx.  The  case  is  remarkable 
for  the  extent  and  situation  of  the  metastatic  deposit.  In  some  cases  recov- 
ery may  follow  in  patients  in  whom  the  disease  develops  from  a  mole  if  the 
ease  be  seen  early.  Poten  and  Vassmer55  report  the  case  of  a  woman,  aged 
thirty-six,  a  multipara,  who  had  cessation  of  menstruation  and  complained 
of  small  tumors  in  the  vagina.  Upon  examination  she  was  found  preg- 
nant, and  the  nodules  in  the  vagina  proved  to  be  malignant.  The  uterus 
was  extirpated  per  vaginam  and  the  nodules  were  removed  from  the  vagina. 
The  patient  was  examined  after  operation,  and  a  small  nodule  found  at 
one  end  of  the  vaginal  wound.  This  was  extirpated,  and  the  patient  dis- 
charged from  the  hospital  apparently  well.  An  interesting  case  with 
excellent  illustrations  and  complete  bibliography  is  published  by  Mar- 
chesi.56  Bacon57  reports  a  case  of  deciduoma  malignum  occurring  in  a  multi- 
para with  an  hydatid  mole.  The  uterus  was  curetted  and  much  placental 
debris  removed,  but  death  followed  rapidly  through  metastases  in  the  lungs. 
Spencer58  reports  a  similar  case,  in  which  the  first  symptom,  the  discharge  of 
masses  of  the  growth,  occurred  twenty-eight  days  after  a  normal  labor  and 
normal  recovery.  The  case  ran  a  rapid  course,  the  patient  dying  of  septic 
infection  ten  and  a  half  weeks  after  the  birth  of  her  child.  Williams 59 
publishes  in  full  the  case  of  a  colored  multipara  who  had  a  long  spontaneous 
birth  and  a  dead  child.  The  placenta  was  soft  and  boggy,  and  there  was 
considerable  hemorrhage  during  the  third  stage  of  labor.  About  two  weeks 
after  the  birth  of  the  child  q,  small  painful  nodule  was  noticed  on  the  right 
labium.  The  growth  extended  with  great  rapidity,  and  the  vagina  sloughed 
and  the  patient  died  of  septic  infection.  Upon  examination  a  deciduoma 
malignum  was  found  present.  Up  to  this  time  twenty-five  cases,  includ- 
ing this  one,  had  been  described.  The  bibliography  and  illustrations  are 
appended. 

Lindfos6"  performed  vaginal  hysterectomy  in  a  case  of  deciduoma  malignum 
very  soon  after  the  delivery  of  an  hydatid  mole.  So  virulent  was  the  disease 
that  the  patient  survived  the  operation  but  five  days.  A  sarcoma  of  the 
decidua  is  reported  by  Monod  and  Chabry.61  This  followed  hydatid  cysts 
of  the  chorion,  the  disease  making  rapid  progress.  Among  the  most  inter- 
esting papers  upon  the  subject  is  that  of  Marchand.62  Under  the  title, 
"  Epithelioma  of  the  Chorion,"  Marchand  expresses  his  view  that  there  are 
two  varieties  of  tumors  of  the  decidua,  typical  and  atypical.  In  the  atypical 
cases  the  tumors  resemble  carcinomatous  or  sarcomatous  growths,  while  the 
typical  cases  always  retain  their  pronounced  chorionic  character.  Marchand 
reviews  the  histological  and  pathological  literature  in  his  paper,  and  it  is 
often  quoted. 


THE   PATHOLOGY    OF  PREGNANCY.  197 

The  method  by  which  the  ovum  embeds  itself  in  the  maternal  tissue  gives 
an  explanation  of  the  mode  of  propagation  observed  in  this  form  of 
malignant  growth.  Peters03  has  described  the  changes  which  take  place  in 
the  tissues  of  the  endometrium  when  the  impregnated  ovum  enters  the 
uterus.  These  strikingly  resemble  the  growth  of  tissue  as  observed  in 
malignant  growth  in  the  decidua.  In  most  of  these  cases  the  pelvic  tissues 
are  extensively  diseased,  but  in  some  no  trace  of  pathological  changes  is 
found  in  the  uterus  or  other  generative  organs. 

Schmorl64  reports  a  case  in  which  the  uterus  was  normal,  but  in  which 
syncytial  tumors  were  present  in  the  kidney,  lungs,  liver,  and  intestines. 
The  disease  probably  followed  an  hydatid  mole,  metastasis  having  begun 
before  the  tumor  was  expelled.  Possibly  some  of  the  normal  chorionic  villi 
were  broken  off  from  the  chorion  and,  carried  to  distant  parts  of  the  bodv, 
set  up  malignant  growth. 

The  writer,  with  Dr.  H.  F.  Harris,65  reports  the  case  of  a  multipara  who 
had  pernicious  nausea  of  pregnancy.  Other  treatment  failing,  the  uterus 
was  emptied.  After  this  the  patient  had  paroxysmal  vomiting,  vertical 
headache,  was  at  times  almost  maniacal,  passed  feces  and  urine  involun- 
tarily, and  died  of  exhaustion.  Upon  autopsy  syncytial  tumors  were  found 
in  the  brain,  in  the  lungs,  kidneys,  and  liver.  The  uterus  was  normal.  In 
this  case,  syncytial  growths  were  suspected  before  death,  but  no  sign  of 
gross  uterine  involvement  was  present.  This  patient  originally  consulted  a 
physician  for  nausea  and  vomiting,  supposing  that  she  had  some  disease  of 
the  stomach.  There  was  nothing  to  call  attention  to  malignant  growth 
except  the  failure  of  the  operation  which  emptied  the  uterus. 

Hypertrophy  of  the  decidua  occurring  during  pregnancy  may  be  non- 
malignant  and  not  dependent  upon  the  existence  of  syphilis.  Thus  Her- 
mann66 describes  cases  of  decidual  hypertrophy  in  which  the  tissue  measured 
one-fiftieth  of  an  inch  in  thickness.  Microscopic  examination  revealed  the 
presence  of  large  cells  with  large  nuclei,  five  or  six  in  number,  without 
intercellular  substance,  but  infiltrated  and  containing  leukocytes.  A  similar 
condition  has  also  been  described  by  Virchow,67  Strassman,63  Dohrn,69  Gus- 
serow,70  Klebs,71  and  Matthews  Duncan.72 

Spontaneous  rupture  of  the  uterus  occasionally  happens  during  preg- 
nancy. Such  cases  are  often  found  to  have  been  complicated  by  the  presence 
of  a  fibroid  tumor,  or  by  displacements  of  the  uterus  with  adhesions  binding 
it  in  its  displaced  position.  Manipulation  intended  to  replace  the  uterus  has 
sometimes  caused  its  rupture  ;  thus  in  a  case  reported  by  Dickey 73  the  patient 
was  in  the  third  month  of  her  fifth  pregnancy.  An  effort  had  been  made 
to  replace  a  retro  verted  womb,  the  effort  causing  the  patient  considerable 
distress.  A  few  days  afterward  something  was  thought  to  give  way,  and 
the  patient  perished  in  a  few  hours  from  shock.  Post-mortem  examination 
showed  early  pregnancy  and  the  uterus  ruptured  transversely  from  one 
Fallopian  tube  to  the  other. 

Spontaneous  rupture  of  the  uterus  may  result  from  the  rapid  development 


198  AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 

of  a  large  fetus  in  a  uterus  whose  tissues  have  been  weakened  by  previous 
disease.  The  fetus  may  escape  into  the  abdominal  cavity,  as  illustrated  in  a 
case  reported  by  Madurowicz,74  in  which  fatty  degeneration  of  the  uterine 
wall  at  the  junction  of  the  fundus  and  cervix  was  found.  The  fetus  had 
become  partially  encapsulated.  Purulent  peritonitis  ensued,  and  the  abdom- 
inal wall  opened  spontaneously  with  a  discharge  of  pus.  The  patient  died 
of  exhaustion. 

In  some  cases  of  rupture  of  the  womb  the  first  symptom  attracting  atten- 
tion is  hemorrhage  from  the  genital  organs.  This  is  followed  by  the  devel- 
opment of  shock,  pain  in  the  abdomen,  and  the  other  signs  of  the  condition 
which  have  long  been  recognized  as  indicative.  Weiss  and  Sehuhl7°  report 
two  cases,  in  the  first  of  which  hemorrhage  was  the  first  symptom  apparent. 
It  was  necessary  to  deliver  the  child  by  basiotripsy,  and  a  fatal  result 
followed.  In  the  second  case  the  child  was  in  breech  presentation,  accom- 
panied by  prolapse  of  the  umbilical  cord.  In  this  case  the  pressure  of  the 
fetal  head  could  not  have  had  an  influence  in  causing  the  rupture,  as  the 
womb  had  torn  before  the  child  was  extracted.  A  transverse  position  of  the 
fetus  has  long  been  recognized  as  predisposing  to  uterine  rupture.  In  some 
cases,  which  are  not  carefully  studied,  the  position  itself  does  not  become 
apparent  until  after  the  womb  has  torn.  Walla70  reports  a  case  in  which 
transverse  position  was  diagnosed  after  the  uterus  had  ruptured.  The  patient 
was  treated  by  extirpation  of  the  womb,  and  made  a  tedious  recovery. 
Walla  gives  the  statistics  of  the  Budapest  clinic,  with  his  case  embracing 
twenty-eight.  In  seventeen  the  tear  was  incomplete,  in  eleven,  complete. 
Of  the  incomplete  ruptures,  ten  died  and  seven  recovered.  They  were 
treated  in  a  conservative  manner  by  draining  the  rent  in  the  uterus  with  iodo- 
form gauze.  Of  the  eleven  complete  ruptures,  six  were  treated  conserva- 
tively, and  all  died.  The  remaining  five  were  subjected  to  operation;  two 
recovered  and  three  died.  Spontaneous  rupture  of  the  womb  may  occasion 
comparatively  slight  symptoms,  and  may  not  be  the  cause  of  death.  Chiari77 
reports  the  case  of  a  multipara,  aged  thirty,  who  had  a  flat  contracted  pelvis, 
and  who  was  delivered  by  craniotomy.  Twenty  days  after  the  birth  of  the 
child  the  patient  died  of  tetanus,  and  upon  autopsy  a  rupture  of  the  uterus 
was  found  which  had  given  no  symptoms  during  life.  The  rupture  extended 
into  the  broad  ligaments,  but  had  not  completely  separated  the  wall  of  the 
uterus.  The  head  of  the  child  had  escaped  into  the  connective  tissue  of  the 
broad  ligament.  No  large  vessel  had  been  torn,  and  hence  no  severe  hemor- 
rhage occurred. 

Some  idea  of  the  danger  of  threatened  uterine  rupture  may  be  gained 
from  the  violence  of  the  mother's  expulsive  efforts.  Doktor78  reports  an 
interesting  case,  in  which  total  extensive  rupture  of  the  uterus  occurred 
following  very  strong  expulsive  pains.  The  patient  was  treated  by  abdom- 
inal section,  and  recovered.  It  has  long  been  known  that  a  second  preg- 
nancy in  a  case  in  which  uterine  rupture  has  occurred  exposes  the  mother 
again  to  the  same  accident.     If  the  mechanism  of  labor  be  favorable  and 


THE   PATHOLOGY    OF  PREGNANCY.  199 

the  mother  be  promptly  delivered,  there  need  be  no  complication  in  a  second 
labor.  Stroganow 79  describes  a  breech  labor  with  extraction  in  a  patient  who 
had  suffered  from  uterine  rupture  in  a  former  labor,  and  whose  life  had  been 
saved  by  abdominal  section.  During  her  convalescence  from  the  second 
labor  some  of  the  silk  sutures  inserted  in  the  uterus  after  the  first  labor  became 
detached  and  were  removed.  A  blow  upon  the  abdomen  during  the  latter 
part  of  pregnancy  has  been  followed  by  rupture  of  the  uterus  at  labor. 
Woodbridge80  reports  such  a  case  in  which  a  pregnant  mother  received  a 
blow  upon  the  abdomen  while  playing  with  a  child.  She  soon  after  came 
into  active  labor  and  had  rupture  of  the  uterus,  from  which  she  died. 

Although  in  itself  almost  invariably  a  fatal  accident,  rupture  of  the  uterus 
may  occur  with  other  very  grave  complications,  and  still  the  patient  may 
recover.  Guerard81  reports  a  case  of  eclampsia  with  twin  pregnancy,  in  which 
the  uterus  was  ruptured  and  the  broad  ligaments  extensively  torn,  and  in 
which  a  piece  of  peritoneum  became  detached  and  lay  in  the  vulva  for  over 
four  hours.  The  children  were  lost,  but  the  mother  was  treated  by  draining 
the  ruptured  uterus  with  gauze  and  recovered.  The  advantages  of  drainage 
are  dwelt  upon  by  many  writers  upon  the  subject,  among  them  Spencer.S2 
Spencer  has  seen  twelve  cases  in  all.  Four  were  treated  by  gauze  drainage 
with  recovery,  and  eight  perished  with  other  treatment.  Schmit83  reports 
from  the  Vienna  clinic  nineteen  cases  treated  by  different  methods,  and 
has  collected  one  hundred  and  seventy-nine.  Of  these,  34.52  per  cent, 
recovered.  These  statistics  show  the  comparative  value  of  drainage,  for  by 
these  methods  51.8  per  cent,  recovered,  while  by  operation  but  25  per  cent, 
escaped  death. 

If  infection  does  not  occur,  the  child  may  remain  in  the  abdomen  of  the 
mother  for  some  time  without  especially  influencing  the  pi'ognosis.  Halban84 
reports  a  case  of  uterine  rupture  in  which  the  fetus  entirely  escaped  from 
the  womb  and  was  retained  within  the  mother's  abdomen  for  fourteen  hours. 
The  patient  was  treated  by  abdominal  section,  and  made  a  good  recovery. 
The  death  of  the  child  commonly  follows  rupture,  as  shown  in  Iwanow's 
case,85  in  which  a  complete  tear  occurred,  the  child  immediately  perishing. 
The  mother  was  treated  by  removing  the  child  as  soon  as  possible,  followed 
by  extirpation  of  the  womb  through  the  vagina.  The  patient  made  a  good 
recovery.  Rupture  of  the  uterus  may  be  followed  by  missed  labor.  Cam- 
eron86 reports  a  case  of  uterine  rupture  after  which  the  womb  retained  the 
child  for  two  months.  At  the  end  of  this  time,  the  patient,  continuing  ill 
and  unable  to  work,  was  examined  by  another  physician,  who  called  a 
council,  when  it  was  found  that  the  uterus  had  ruptured.  The  child  was 
much  softened  and  the  placenta  completely  organized  and  detached.  The 
placenta  had  escaped  into  the  abdominal  cavity,  whence  it  was  taken.  The 
patient  died  soon  after  her  delivery. 

That  a  patient  may  survive  uterine  rupture  and  almost  incredible  violence 
to  the  genital  organs  is  illustrated  in  a  case  reported  by  Burger.87  The 
patient  had  a  transverse  position  of  the  fetus  and   the  uterus  ruptured  in 


200  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

labor.  She  could  not  be  taken  to  a  hospital,  and  nothing  could  be  done 
except  to  extract  the  fetus  by  version  and  deliver  the  placenta.  The 
mother's  intestines  protruded  from  the  rent  in  the  uterus.  These  were 
replaced  and  the  hand  kept  in  the  uterus  until  it  contracted  firmly.  The 
tear  was  closed  by  the  firm  uterine  contraction,  and  but  little  hemorrhage 
occurred.  The  patient  did  well  until  the  sixth  day,  when  she  was  violently 
assaulted  by  her  drunken  husband.  She  recovered  from  this  and  was 
delivered  of  a  living  child  nine  months  and  six  days  afterward.  The 
placenta  was  adherent  to  the  site  of  the  former  rupture  and  was  delivered 
manually.  A  year  later  the  patient  died  of  hemorrhage  from  an  adherent 
placenta  before  assistance  could  reach  her. 

Among  the  causes  of  uterine  rupture  which  must  be  recognized  is 
placenta  prsevia.  Schutze83  reports  a  case  of  placenta  prsevia  in  which  version 
was  necessary  to  stop  bleeding.  The  os  would  admit  but  three  fingers,  but 
the  cervix  was  very  soft  and  the  version  was  readily  made.  The  child  was 
easily  born.  The  mother  perished  soon  after  from  severe  hemorrhage,  found 
to  be  caused  by  incomplete  rupture  of  the  uterus. 

Neither  pelvic  contraction  nor  abnormal  position  of  the  fetus  is  necessary 
for  uterine  rupture.  Dakin S9  reports  the  case  of  a  multipara  w ith  normal 
pelvis  and  child  in  normal  position.  The  patient  was  not  well  nourished,  and 
as  labor  halted,  she  was  delivered  very  easily  by  forceps.  The  placenta  did 
not  come  away,  and  upon  introducing  the  hand  the  uterus  was  found  ruptured 
and  the  placenta  protruding  through  the  rent.  The  patient  died  in  collapse. 
On  autopsy  the  tear  extended  almost  horizontally  through  the  placental  site 
and  then  upward.  A  microscopic  examination  of  the  muscle-fibers  of  the 
uterus  showed  them  to  be  in  fatty  degeneration  and  very  friable. 

The  pathology  of  abortion  affords  numerous  examples  of  the  rupture  of 
the  uterus  by  the  sound  of  the  abortionist.  Orthmann  90  describes  the  case  of  a 
multipara  who  had  an  apparently  spontaneous  abortion  between  the  third 
and  fourth  month.  As  the  membranes  were  retained,  examination  was 
made,  and  rupture  of  the  uterus  found  on  the  right  side,  through  which  the 
membranes  had  escaped.  The  abdomen  was  opened,  and  blood  found  be- 
tween the  layers  of  the  right  broad  ligament.  The  fetal  appendages  had 
escaped  into  the  broad  ligament,  and  it  was  necessary  to  make  an  incision 
through  the  peritoneal  covering  and  to  remove  clots  and  appendages.  The 
broad  ligament  and  uterus  were  closed  with  catgut,  and  the  patient  recovered. 

The  extraction  of  the  child  by  abdominal  section  after  rupture  of  the 
uterus  naturally  suggests  itself  as  a  feasible  expedient.  Pee91  describes  a 
case  of  shoulder  presentation  in  which  version  failed,  the  uterus  having 
ruptured.  Owing  to  intensely  cold  weather,  the  patient  could  not  be  taken 
to  a  hospital,  and  hence  abdominal  section  was  done  at  her  home  and  the 
child  extracted.  The  uterus  was  completely  emptied,  and  the  tear  closed 
with  fine  silk,  the  peritoneal  covering  of  the  womb  with  catgut,  and  the 
abdomen  closed  without  drainage.     Complete  recovery  followed. 

The  treatment  of  uterine  rupture  is  extensively  reviewed  by  Ludwig.9- 


THE   PATHOLOGY   OF  PREGNANCY.  201 

He  urges  vaginal  delivery  of  the  child  if  possible,  unless  the  child  has 
entirely  escaped  into  the  abdomen.  The  use  of  the  tampon  and  compression 
of  the  womb  are  demanded  only  in  incomplete  rupture.  It  is  occasionally 
possible  to  suture  the  tear  by  operating  through  the  vagina.  Where,  how- 
ever, the  conditions  are  favorable  for  union,  abdominal  section  gives  the  best 
result.  In  the  presence  of  bleeding  and  collapse  abdominal  section  should 
be  employed.  In  the  presence  of  this  accident  any  protruding  portion  of 
the  child  should  be  replaced  within  the  uterus  if  possible  before  version  is 
made;  thus,  Queisner93  replaced  the  right  leg  of  a  fetus  which  had  emerged 
through  a  tear  in  the  womb,  made  version,  and  delivered  the  patient.  A 
bag  of  sand  was  laid  upon  the  womb,  which  contracted  well,  and  opium  was 
given  freely.  The  patient  recovered.  The  cause  of  uterine  rupture  was 
hard  to  trace  in  this  case,  unless  the  very  anemic  patient  had  induced 
rupture  by  lifting  heavy  weights. 

An  interesting  and  unusual  complication  following  rupture  of  the  uterus 
is  subperitoneal  emphysema.  Dischler94  reports  two  cases  from  the  Dresden 
Maternity.  If  air  has  entered  the  uterine  cavity  prior  to  rupture  or  gases 
of  putrefaction  are  formed  within,  these  gases  enter  through  the  laceration, 
producing  emphysema.  Its  exact  situation  varies  in  accordance  with  the 
intra-uterine  and  intra-abdominal  pressure,  and  also  whether  the  peritoneum 
is  intact  or  lacerated.  Such  emphysema  is  a  positive  symptom  of  rupture  of 
the  uterus  and  adds  greatly  to  the  dangers  through  the  rapid  spreading  of 
infectious  material.  In  Disorder's  opinion,  the  occurrence  of  well-marked 
intra-uterine  emphysema  with  subperitoneal  emphysema  is  an  indication  for 
immediate  hysterectomy.  Rupture  of  the  uterus  during  pregnancy  may 
occur  in  a  patient  who  has  had  repeated  pregnancies  with  some  abnormality 
in  the  structure  of  the  uterus  which  weakens  its  tissues.  Jellinghaus 95 
describes  an  interesting  case  in  a  multipara  in  the  sixth  month  of  pregnancy, 
a  hard-working  woman,  who  had  fallen  from  a  window  and  was  suffering 
from  bleeding  and  pain.  Abortion  proceeded  slowly,  and  the  patient  was 
given  a  laxative  to  move  the  bowels.  She  had  thin  bowel  movements,  and 
the  uterus  gradually  grew  tense  and  the  abdomen  distended.  There  was 
dulness  in  the  lower  portion  of  the  abdomen.  This  gradually  increased, 
the  abdomen  becoming  painful,  with  considerable  distention.  Upon  section 
the  uterus  was  found  ruptured.     The  patient  recovered  after  hysterectomy. 

The  removal  of  the  cancerous  cervix  leaves  the  uterus  in  a  condition  in 
which  rupture  is  likely  to  occur  should  pregnancy  supervene.  Bovee96 
reports  the  case  of  a  multipara  whose  cervix  had  been  removed  for  cancer. 
She  recovered  from  this,  and  then  had  an  abortion  and  the  removal  of  the 
placenta  by  the  curet.  When  eight  months  pregnant  she  came  into  pre- 
mature labor,  and  extensive  rupture  of  the  uterus  occurred  through  efforts  at 
spontaneous  parturition.     The  patient  died  of  shock. 

Patients  suffering  from  tuberculosis  are  also  liable  to  uterine  rupture 
from  the  weakened  condition  of  the  uterine  muscle.  Brown97  reports  a  case 
in  charge  of  a  midwife,  the  patient  being  emaciated  with  tuberculosis.     The 


202  AMERICAN   TEXT- BOOK   OF   OBSTETRICS. 

midwife  gave  a  large  dose  of  ergot,  causing  severe  pain.  Face  presentation 
developed  and  the  uterus  ruptured,  followed  quickly  by  death.  The  wall  of 
the  womb  was  about  an  eighth  of  an  inch  in  thickness. 

In  a  patient  debilitated  by  chronic  metritis  and  digestive  disturbances 
Hypes98  saw  rupture  of  the  uterus  follow  violent  vomiting,  with  the  usual 
symptoms  of  rupture  of  the  womb.  The  patient  had  been  in  labor  but  a 
comparatively  short  time,  the  only  treatment  employed  having  been  an  injec- 
tion of  morphin.  This  patient  perished  from  shock  before  treatment  could 
be  instituted.  On  examination  the  point  of  rupture  was  found  to  be  upon 
the  anterior  surface  of  the  fundus.  The  patient  had  borne  a  child,  and  the 
placenta  had  been  adherent  and  delivered  manually,  followed  by  curetting. 
Infection  occurred  at  this  time,  which  weakened  the  wall  of  the  uterus  at  the 
placental  site. 

It  is  natural  to  expect  rupture  of  the  uterus  in  cases  in  which  direct 
violence  is  applied  to  the  abdomen  of  the  pregnant  woman.  This  finds 
illustration  in  Reissing's  case."  A  woman,  aged  twenty-three,  at  eight 
months,  primigravida,  fell  a  distance  of  about  twelve  feet  upon  hard  ground. 
The  uterus  ruptured  longitudinally  at  the  placental  site,  with  escape  of  the 
fetus  into  the  abdominal  cavity.  The  patient  was  treated  by  section,  suture 
of  the  rent,  and  drainage  through  the  vagina,  followed  by  recovery. 

While  dislocation  of  the  viscera  cannot  be  considered  traumatism,  still 
such  may  place  the  uterus  in  a  position  in  which  the  exercise  of  uterine  con- 
tractions may  result  in  rupture.  Among  the  more  unusual  dislocations  of 
the  viscera  are  displacements  of  the  kidneys,  which  are  occasionally  found  as 
far  down  in  the  abdomen  as  the  brim  of  the  pelvis.  Albers-Schoenberg100 
describes  the  case  of  a  multipara  whose  uterus  ruptured  spontaneously  after 
a  labor  of  fourteen  hours'  duration.  The  rent  was  anterior,  just  above  the 
vagina.  The  child  was  in' the  second  position,  the  vertex  anterior,  and  the 
head  projecting  into  the  tear  in  the  uterus.  A  dead  female  child  was 
delivered  by  version  and  the  placenta  was  extracted.  As  severe  symptoms 
were  absent,  it  was  thought  that  the  tear  did  not  extend  through  the  peri- 
toneum, and  section  was  deferred.  On  the  fifth  day  operation  was  per- 
formed for  beginning  infection  of  the  peritoneum ;  but  the  tear  could  not  be 
found,  as  it  was  concealed  by  coagulated  blood  and  fragments  of  tissue. 
The  patient  died  after  the  operation.  Upon  examination  the  uterus  was 
found  completely  torn  through.  The  pelvis  was  a  flat  rachitic  pelvis,  and 
the  left  kidney  lay  in  the  hollow  of  the  sacrum  and  upon  the  promontory. 
This  and  the  contraction  of  the  pelvis  had  forced  the  occiput  against,  the 
anterior  uterine  wall  and  rupture  had  resulted.  A  similar  mechanism  of 
uterine  rupture  is  present  in  some  abnormal  labors  in  which  the  natural 
mechanism  of  delivery  fails.  Face  presentation,  posterior  rotation  of  the 
occiput,  presentation  of  the  parietal  bone,  brow  presentation,  and  very  slow 
and  deficient  rotation,  may  all  in  a  weakened  uterus  result  in  rupture.  Coe 101 
reports  the  case  of  a  strong  woman,  a  multipara,  with  normal  labor,  who  had 
a    posterior    rotation    of  the    occiput  toward   the   right  side.     The   patient 


THE  PATHOLOGY   OF  PREGNANCY.  203 

expelled  the  child  without  assistance,  the  infant  being  stillborn  and  weighing 
ten  pounds  seven  ounces.  The  placenta  was  expressed,  and  there  was  no 
post-partum  hemorrhage,  the  uterus  contracting  firmly.  Five  hours  after 
delivery  the  patient  was  found  in  collapse,  with  the  uterus  apparently  well 
contracted.  A  deep  laceration  was  found  upon  the  left  side  of  the  cervix 
extending  into  the  body  of  the  uterus.  On  section  a  large  hematocele  was 
present  in  the  left  broad  ligament,  which  had  gradually  formed  after  expul- 
sion of  the  child.  The  case  resulted  fatally.  There  had  been  no  external 
hemorrhage  to  call  attention  to  the  condition. 

Coe  reports  a  case  102  in  which  the  uterus  was  entirely  removed  because 
transverse  rupture  had  occurred  with  prolapse  of  the  intestine.  The  case  is 
interesting  because  it  illustrates  the  possibility  of  operation  upon  a  patient 
weighing  two  hundred  and  fifty  pounds  and  in  a  dwelling.  The  patient 
could  not  be  placed  upon  a  table,  but  remained  in  her  bed  during  the 
operation. 

Cases  of  uterine  rupture  may  occur  as  an  indirect  result  of  violent 
removal  of  the  placenta.  It  seems  scarcely  probable  that  placental  removal 
only  could  rupture  the  uterus  did  not  infection  accompany  the  placental 
removal.  A  typical  case  of  this  sort  is  reported  by  Hektoen.103  The  patient 
was  a  healthy  woman,  the  mother  of  one  child,  and  was  pregnant  four 
months.  She  was  seized  with  abdominal  pain  after  vigorous  exertion  in 
washing  windows.  The  expulsion  of  the  fetus  was  spontaneous,  but  what 
was  described  as  the  placenta  was  removed  by  the  midwife  by  pulling  upon 
the  cord.  Severe  abdominal  pain  and  other  unfavorable  symptoms  de- 
veloped, and  physicians  were  called.  The  uterine  cavity  was  scraped  care- 
fully with  a  dull  curet,  and  an  intra-uterine  antiseptic  douche  given,  only 
part  of  which  returned.  The  patient  died,  with  rapid  development  of 
intense  septic  infection.  The  entii'e  fundus  of  the  uterus  and  the  greater 
part  of  the  broad  ligaments  had  disappeared.  It  seems  most  likely  that 
pulling  upon  the  cord  produced  a  partial  inversion  of  the  fundus,  and  that 
the  uterine  tissue  was  mistaken  for  the  placenta  and  was  gouged  out  by  the 
finger  of  the  midwife  in  attempting  to  pull  away  the  after-birth. 

Important  questions  in  connection  with  this  subject  are — first,  In  what 
way  shall  the  child  be  removed  ?  and  second,  What  shall  be  done  with  the 
uterus  ? 

These  questions  receive  consideration  by  Slechta.104  Most  writers  agree 
that  if  the  child  escapes  through  the  ruptured  uterus  into  the  abdomen, 
abdominal  section  must  be  done.  The  same  is  true  when  only  a  part  of  the 
child  has  passed  through  the  rupture,  but  the  rest  is  high  in  the  pelvis,  so 
that  it  cannot  be  reached  through  the  vagina.  If  the  presenting  part  of  the 
child  has  not  slipped  out  of  the  pelvis,  it  may  be  delivered  in  the  natural 
way — that  is,  by  extraction  or  the  use  of  forceps,  or  perforation  and  extrac- 
tion with  the  cranioclast.  In  transverse  presentation  embryotomy  is  the 
safest  plan.  If  an  arm  has  come  down,  the  child  should  be  decapitated. 
Version  should  not  be  performed,  because  of  the  danger  of  enlarging  the  tear. 


204  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

The  placenta  should  not  be  removed  by  pressure,  but  must  be  taken  manu- 
ally. Should  the  placenta  have  passed  through  the  laceration  into  the  abdo- 
men, the  abdomen  must  be  opened. 

There  is  greater  difference  of  opinion  regarding  the  best  method  of 
dealing  with  the  ruptured  uterus.  Piskacek  reports  eighty  cases  of  complete 
rupture,  of  which  56.1  per  cent,  of  those  treated  by  tampon  died,  while  60.8 
per  cent,  of  those  treated  by  section  perished.  In  incomplete  rupture  most 
writers  use  the  gauze  tampon. 

If  section  is  performed,  the  tear  in  the  uterus  may  be  closed  or  the  womb 
entirely  removed.  Which  shall  be  done  depends  upon  the  situation  of  the 
rupture,  the  condition  of  the  uterus,  and  the  probability  that  infection  is 
present  or  the  chance  that  infection  is  absent.  Each  case  must  be  decided 
upon  its  individual  merits.  Slechta'"4  reports  eight  eases  of  rupture  of  the 
womb  occurring  in  the  Prague  clinic.  Three  of  these  were  perforating,  and 
all  died.  Five  were  incomplete,  and  recovered.  His  method  of  using  the 
tampon  is  as  follows :  The  exact  seat  of  rupture  is  carefully  determined  and 
the  uterus  disinfected  with  thymol  or  boric  acid.  The  uterus  is  pushed  down 
through  the  abdominal  wall  until  the  edges  are  approximated  as  closely  as 
possible.  The  womb  must  then  be  held  in  this  position  until  hemorrhage 
ceases.  Strips  of  gauze  are  passed  to  the  upper  border  of  the  tear  and 
packed  in  and  about  the  wound.  The  cervix  and  vagina  are  packed  with 
gauze.  If  there  is  hemorrhage,  a  drainage-tube  is  introduced  between  the 
folds  of  gauze.  This  tube  protrudes  from  the  vagina,  and  irrigation  may  be 
carried  on  through  it.  An  ice-bag  is  placed  over  the  uterus,  opium  is  given, 
and  the  urine  drawn  by  catheter.  The  gauze  is  removed  on  the  ninth  or 
tenth  day. 

Endometritis  during-  pregnancy  results  from  an  aggravation  of  a  pre- 
existing inflammatory  condition,  and  it  is  a  familiar  and  frecpient  cause  of 
earlv  abortion.  In  patients  who  complete  the  period  of  gestation  the  exist- 
ence of  this  condition  may  be  suspected  when  occasional  discharges  of  blood 
or  of  watery  mucus  occur.  While  the  pregnancy  is  not  likely  to  go  on  to 
term,  still  its  continuance  must  not  be  despaired  of  because  of  these  dis- 
charges. An  endometritis  set  up  or  aggravated  by  pregnancy  not  infre- 
quently causes  adherence  of  the  membranes  about  the  cervix  and  the  lower 
uterine  segment,  often  complicating  labor  by  premature  rupture  of  the  bag 
of  waters  and  protracted  dilatation  of  the  birth-canal.  It  is  noticed  in 
women  who  conceive  shortly  after  an  abortion  that  an  endometritis  arising  at 
the  abortion  may  persist  throughout  pregnancy,  becoming  aggravated,  and 
resulting  finally  in  the  firm  adherence  of  the  placenta  and  in  complicated 
labor ;  thus,  Lohlein  105  reports  a  case  of  this  character  in  which  the  preg- 
nancy went  to  term,  its  latter  portion  being  complicated  by  intermittent 
pyrexia  and  by  a  very  firmly  adherent  placenta. 

The  treatment  of  this  condition  is  entirely  in  the  interest  of  the  mother, 
as  the  prospect  of  her  retaining  the  ovum  to  maturity  is  so  slight  that 
exhausting  hemorrhage  or  febrile  disturbance  should  lead  to  prompt  empty- 


THE   PATHOLOGY   OF  PREGNANCY.  205 

ing  of  the  uterus.  This  should  only  be  done  in  the  most  thorough  surgical 
manner  and  under  strict  antiseptic  precautions.  Sufficient  dilatation  to  per- 
mit the  use  of  the  sharp  curet  and  of  drainage  should  be  secured  by  using 
the  fingers  or  solid  metal  dilators.  Should  septic  infection  and  fever  be 
present,  the  blunt-edged  douche-curet  may  be  employed  to  great  advantage, 
thoroughly  emptying  the  uterus  under  a  stream  of  antiseptic  fluid.  Where 
sepsis  and  fever  are  absent  the  sharp  curet,  followed  by  antiseptic  irrigation, 
will  be  found  efficient.  Drainage  with  iodoform  gauze,  with  repeated 
intra-uterine  irrigation,  is  indicated  should  fever  and  foul  discharge  continue. 
Curetting  is  best  performed  at  the  time  of  abortion  or  premature  labor ;  or, 
if  this  opportunity  is  omitted,  it  should  be  done  when  the  patient  has 
recovered  strength  and  the  interior  of  the  uterus  has  ceased  to  furnish  a  foul 
discharge. 

Infection  of  the  decidua  and  fetal  membranes  occurring  during  preg- 
nancy is  undoubtedly  present,  although  unrecognized,  in  a  considerable 
number  of  cases.  As  a  result,  adhesion  of  the  membranes  may  occur, 
resulting  in  premature  rupture  and  the  early  loss  of  amniotic  liquid.  Slow 
dilatation  of  the  os  and  cervix  and  the  complications  which  follow  premature 
rupture  of  the  membranes  occur  in  these  cases.  The  literature  of  the  sub- 
ject is  scanty,  and  the  following  case  under  the  observation  of  the  writer 
merits  description  :  The  patient  was  a  multipara,  aged  thirty,  in  her  sixth 
pregnancy.  She  had  given  birth  to  two  full-term  children  and  had  had 
three  stillbirths.  The  history  of  syphilis  could  not  be  obtained  from  either 
father  or  mother.  She  had  been  in  good  health  during  pregnancy  and  was 
not  especially  neurotic.  She  came  under  the  care  of  the  Jefferson  Maternity, 
and  Dr.  William  A.  Ewing,  then  a  senior  student,  made  an  especial  study 
of  the  case.     The  observations  reported  are  his. 

The  patient  complained  of  a  sudden  rush  of  water  from  the  vagina  after 
carrying  a  weight  of  about  fifty  pounds  up  five  flights  of  stairs.  This  was 
followed  by  slight  rise  in  temperature  and  pulse,  and  by  the  discharge  of 
small  quantities  of  fluid  with  small  quantities  of  blood.  Upon  examination 
the  abdomen  was  large  and  flabby,  the  fetus  in  second  position,  vertex  pres- 
entation. The  period  of  gestation  was  approximately  thirty  weeks.  There 
was  no  pelvic  abnormality.  On  vaginal  examination  no  evidence  could  be 
found  pointing  to  rupture  of  the  membranes.  The  finger  could  be  passed 
through  the  os,  and  fluid  could  be  detected  within  the  membranes.  There 
was  slight  oozing  of  blood,  and  no  odor  to  the  discharge  and  no  evidence  of 
placenta  pragvia.  Rest  in  bed  and  anodynes  prevented  the  occurrence  of 
labor,  although  a  slight  discharge  persisted.  A  sample  of  the  fluid  escaping 
was  obtained  with  care  and  examined  at  the  Laboratories  of  Jefferson 
Medical  College.  It  was  grayish,  cloudy  with  flocculent  sediment,  of  acid 
reaction,  specific  gravity  1021,  a  trace  of  albumin,  chlorids  0.45,  urea  0.9 
per  cent.  It  contained  squamous  epithelia,  leukocytes,  and  bacilli,  but  no 
erythrocytes.  Examination  showed  that  the  fluid  was  amniotic,  and  not  that 
of  hydrorrhtt'a  gravidarum.     The  blood  of  the  patient  contained  4,800,000 


206  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

erythrocytes,  8500  leukocytes,  and  70  per  cent,  hemoglobin.  The  patient  was 
admitted  to  the  wards  and  placed  in  bed,  her  general  condition  improving 
with  rest,  when  spontaneous  labor  came  on.  The  membranes  ruptured  almost 
immediately,  but  no  gush  of  fluid  occurred,  a  slight  trickling  showing  a 
quantity  of  liquid  remaining.  A  male  child  weighing  four  pounds  eleven 
and  a  quarter  ounces  was  spontaneously  born.  The  cord  was  twice  about  the 
neck.  The  child  died  of  inanition  between  three  and  four  weeks  after  deliv- 
ery. The  patient's  recovery  was  complicated  by  moderate  rise  of  tempera- 
ture and  by  a  foul  and  profuse  uterine  discharge.  The  uterus  was  twice 
washed  out,  no  remains  of  the  placenta  being  found,  the  temperature  gradu- 
ally subsiding  and  the  patient  making  a  good  recovery. 

The  placenta  was  large,  soft,  boggy,  and  friable.  The  membranes  showed 
no  visible  tear.  The  amnion  stripped  from  the  chorion  more  easily  than 
usual.  The  amnion  was  perfectly  transparent.  The  chorion  was  thick, 
opaque,  shaggy,  and  friable,  especially  near  the  placenta.  Microscopic  exam- 
ination of  the  chorion  frondosum  and  chorion  lseve  showed  a  true  suppurative 
inflammation  with  small  areas  of  coagulation-necrosis.  An  abundance  of 
multinuclear  leukocytes  was  present,  with  a  diplococcus  not  staining  by 
Gram's  method.  The  chorion  was  swollen  with  leukocytes  and  engorged 
with  the  watery  constituents  of  the  blood.  In  view  of  the  antiseptic  pre- 
cautions taken  in  the  conduct  of  the  case  and  the  fact  that  rupture  of  the 
membranes  occurred  some  time  before  delivery,  this  process  must  be  con- 
sidered as  antedating  for  some  time  the  patient's  labor.  When  the  abundance 
of  bacteria  found  in  the  vagina  is  considered,  the  occurrence  of  infection  of 
the  chorion  cannot  be  regarded  with  surprise.  The  accompanying  illustra- 
tions show  the  conditions  present  in  the  case. 

Salpingitis  existing  during  pregnancy  complicates  the  pregnant  condi- 
tion largely  by  reason  of  cthe  adhesions  and  the  inflammatory  exudates 
usually  present  with  the  salpingitis.  As  the  uterus  increases  in  size  tension 
upon  these  adhesions  causes  very  considerable  pain,  and  if  the  adhesions  are 
firm,  binding  down  the  uterus,  abortion  is  not  infrequently  the  final  result. 
A  frequent  cause  of  retroversion  and  retroflexion  of  the  gravid  uterus  is  to 
be  found  in  salpingitis,  and  in  the  adhesions  and  exudates  which  accompany 
this  condition  ;  in  such  cases  obstinate  nausea  and  vomiting,  and  finally  abor- 
tion, may  be  the  direct  consequence  of  the  salpingitis  present.106  107  Salpin- 
gitis is  by  no  means  a  trifling  complication  of  pregnancy,  as  cases  are  recorded 
in  which  acute  sepsis,  with  general  peritonitis  developing  twenty-four  hours 
after  labor,  has  caused  death.  It  is  certainly  true  that  a  patient  suffering 
from  salpingitis  should  avoid  pregnancy,  and  should  subject  herself  to  prompt 
and  thorough  treatment  if  the  liability  to  pregnancy  exists. 

Diseased  conditions  of  the  ovary  complicating  pregnancy  are  usually 
made  worse  bv  the  gravid  condition ;  thus,  ovarian  cysts,  solid  tumors  of 
these  organs,  and  inflammatory  conditions  are  greatly  aggravated  during 
pregnancy.  Acute  oophoritis  complicating  pregnancy  is  of  rare  occurrence, 
and  it  may  result  from  an  exacerbation  of  a  chronic  process  or  septic  infec- 


THE   PATHOLOGY    OF   PREGNANCY. 


207 


tion  from  a  previous  abortion.  Three  cases  of  this  affection  are  reported  by 
Coe;10S  in  each  of  two  cases  tubal  and  ovarian  abscess  formed  and  was 
emptied.     All  three  patients    recovered,  although    convalescence   was  pro- 


Fig.  142.— a,  Amnion;  6,  chorion;  c,  chorionic  villi;  d,  areas  of  active  leukocytic  inflltrati 
complete  necrosis  and  pus-formation. 

longed.     The  treatment  of  this  condition   is  largely  expectant,  abdominal 
section  being  most  successful  before  the  fifth  month  of  pregnancy. 

Thomson  109  has  shown  that  while  the  tubes  undergo  a  marked  hypertro- 
phy during  pregnancy,  the  ovary  itself  does  not.     The  alterations  observed 


Fig.  113.—  a,  Normal  counective-tissue  cells  of  the  chorion ;  b,  polymorphonuclear  leukocytes :  c,  bacteria. 

in  the  ovaries  during  pregnancy  are  caused  by  foreign  growths,  and  not  by 
the  increase  of  elements  normally  present.  In  addition  to  the  danger  of 
abortion  which  the  size  of  an  ovarian  tumor  occasions,  there  is  a  possible  risk 


208  AMERICAN    TEXT-BOOK    OE    OBSTETRICS. 

that  such  a  tumor  may  twist  its  pedicle,  and  that  gangrene  may  be  added  to 
the  complications  of  labor  in  this  condition.  It  has  repeatedly  been  shown 
that  the  operation  of  ovariotomy  is  safe  and  satisfactory  during  pregnancy, 
and  this  fact  calls  for  the  removal  of  ovarian  tumors  as  soon  as  their  presence 
is  detected.  In  these  cases  adhesions  are  not  often  present,  nor  does  the 
pregnant  condition  predispose  to  their  formation. 

The  rapid  development  of  a  cystic  condition  of  the  ovary  may  com- 
pletely mask  an  early  pregnancy,  as  in  a  case  reported  by  Polaillon,""  in 
which  pregnancy  could  not  positively  be  diagnosed  until  a  cystic  ovary  and 
an  adherent  tube  were  removed.  This  operation  did  not  interfere  with  the 
pregnant  condition,  the  patient  going  to  term  and  being  delivered  of  a 
healthy  child. 

Spontaneous  cure  of  a  pelvic  cyst  complicating  pregnancy  occasionally 
happens  in  the  case  of  broad-ligament  cysts,  which  disappear  by  spontaneous 
rupture.  Rugem  describes  a  case  four  months  pregnant  in  which  under 
anesthesia  a  pelvic  cyst  was  pushed  up  above  the  brim  of  the  pelvis,  relieving 
pressure  upon  the  uterus.  Abortion  followed,  and  after  recovery  the  abdo- 
men was  opened  ;  no  cyst  was  found,  and  its  disappearance  is  ascribed  to 
spontaneous  rupture.  The  evidence  in  favor  of  the  operative  treatment  of 
ovarian  cysts  complicating  pregnancy  is  greatly  in  the  ascendant  over  any 
other  form  of  treatment ;  this  is  shown  by  the  results  of  Schroeder  and 
Olshausen,  Flaischlen,11-  and  Dsirne;"3  the  mortality  of  the  operation 
ranges  from  9.8  per  cent,  to  5.9  per  cent. 

Mangiagalli lu  and  Acconci  "5  similarly  report  good  results  from  ovari- 
otomy during  pregnancy. 

Terrillon  U6  advises  against  puncture  of  ovarian  cysts  during  pregnancy, 
and  urges  ovariotomy  not  earlier  than  the  third  nor  later  than  the  fifth 
month.  ' 

Fehling117  reports  two  hundred  and  sixty-six  abdominal  sections  for 
ovarian  tumors  complicating  pregnancy,  with  5.4  per  cent,  mortality.  This 
is  about  the  mortality-rate  of  ovariotomy  under  all  circumstances.  Thirty- 
three  per  cent,  of  the  children  were  lost  through  abortion  or  premature 
labor.  Fehling  calls  attention  to  the  difficulties  of  diagnosis  when  the 
tumor  is  large  and  soft,  and  urges  the  extraction  of  some  fluid  from  the  cyst 
throligh  the  abdominal  wall,  which  gives  opportunity  for  detecting  the 
characteristics  of  ovarian  fluid.  Kreutzmann  lls  draws  attention  to  six  cases 
of  ovarian  tumors  complicating  pregnancy  which  he  treated  by  operation. 
Many  of  these  were  operations  of  necessity  and  not  of  election,  as  the  patient 
was  not  seen  until  well  advanced  in  labor.  The  results  for  the  mother  were 
good  in  nearly  all  cases,  while  but  a  small  percentage  of  the  children  were 
lost. 

Ovarian  tumors  complicating  pregnancy  are  dangerous  not  only  because 
of  the  mechanical  obstruction  to  labor  which  they  occasion,  but  also  for  the 
reason  that  the  contents  of  most  of  these  tumors  are  infectious  to  the  perito- 
neum.    Hence  the  rupture  of  a  tumor  without  a  twist  of  the  pedicle  may  be 


THE  PATHOLOGY   OF  PREGNANCY.  209 

followed  by  peritonitis.  If  the  tumor  be  of  any  size,  the  process  of  labor 
affects  the  condition  of  its  contents  and  sets  up  a  change  in  its  organization 
not  easily  explained,  but  which  increases  its  infective  property.  An  un- 
ruptured cyst  may  manifest  the  first  signs  of  infection  several  days  after 
labor,  when  under  ordinary  circumstances  such  danger  would  have  passed. 
MacNaughton  Jones U9  reports  the  case  of  a  primipara  who  manifested 
symptoms  of  abdominal  infection  on  the  fifth  day  after  her  delivery.  Fever 
gradually  subsided,  and  on  the  eighteenth  day  after  labor  her  pulse  became 
practically  normal.  The  abdomen  increased  in  size,  and  it  was  evident  that 
an  infective  cystic  tumor  was  present.  Operation  was  performed  on  the 
forty-third  day  after  labor,  when  a  cyst  filled  with  pus  was  removed.  It  was 
very  adherent  and  its  removal  very  difficult.  The  pus  was  inodorous.  The 
patient  made  an  uninterrupted  recovery  after  the  operation. 

In.  contrast  with  the  difficulty  experienced  at  this  operation  is  the  history 
given  by  Bland  Sutton,120  of  a  case  operated  upon  as  follows:  A  primipara 
had  been  in  labor  about  twenty  hours,  a  large,  tense,  semifluid  mass  occupy- 
ing the  outlet  of  the  pelvis.  She  was  brought  to  a  hospital,  and  operation 
performed  as  soon  as  possible.  The  head  of  the  fetus  was  so  thoroughly  im- 
pacted in  the  pelvis  that  it  could  not  be  extricated,  and  accordingly  the 
uterus  was  incised  and  emptied.  It  was  closed  with  two  layers  of  silk 
suture.  The  tumor  was  then  removed  from  the  pelvis  and  found  to  have  a 
long,  slender  pedicle,  which  was  readily  ligated.  The  mother  and  child  made 
an  uninterrupted  recovery.  The  tumor  was  a  dermoid  with  a  single  cavity, 
containing  pultaceous  matter  mixed  with  hair  and  one  piece  of  bone.  Sutton 
also  reports  the  case  of  a  multipara  whose  labor  was  obstructed  by  a  pelvic 
tumor.  The  patient  was  urged  to  come  to  a  hospital,  but  her  physician  suc- 
ceeded in  pushing  up  the  tumor  and  delivering  the  child  with  forceps.  On 
the  third  day  she  had  symptoms  of  abdominal  infection.  On  section  an 
ovarian  tumor  with  a  twisted  pedicle  was  removed.  The  abdomen,  however, 
had  become  infected  and  the  patient  died.  Sutton  urges  that  ovarian  tumors 
complicating  pregnancy  should  not  be  left  without  operation.  An  ovarian 
cyst  may  rupture  the  uterus,  or  the  vagina  may  rupture,  or  the  tumor  may 
be  extruded  into  the  rectum.  Thus  Ward121  reports  a  case  in  which  a  cyst 
in  the  right  ovary  as  large  as  a  cocoanut  prevented  the  head  from  entering 
the  pelvis.  The  uterus  ruptured  and  the  woman  died.  Kerswill 122  saw  a 
case  in  which  an  ovarian  cyst  was  forced  through  a  rent  in  the  vagina  with- 
out breaking  its  pedicle.  Alexsenko  describes  a  case  in  which  an  ovarian 
dermoid  obstructing  labor  had  been  forced  into  the  rectum,  invaginating  the 
wall  of  the  rectum  and  appearing  through  the  anus.  The  mucous  mem- 
brane was  incised,  the  pedicle  tied,  and  the  tumor  removed.  The  patient 
recovered. 

In  Brewer's  case  123  an  ovarian  cyst  obstructing  delivery  burst  and  its  con- 
tents escaped  through  a  rent  in  the  vagina.  The  woman  recovered.  Berry124 
reports  the  case  of  a  woman  in  labor  with  her  tenth  child  delivered  by  for- 
ceps.   That  same  evening  the  patient  coughed  and  felt  something  escape  from 


210  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

the  vagina.  It  proved  to  be  an  ovarian  cyst,  whose  pedicle  was  ligated  and 
the  tumor  removed.  The  patient  recovered.  In  Griffith's  case125  a  solid 
tumor  of  the  ovary  obstructed  delivery.  He  performed  craniotomy  and  ver- 
sion and  delivered  with  great  difficulty.     The  mother  died. 

Sutton  reports  the  case  of  a  young  married  woman  who  had  been  twice 
delivered  of  stillborn  children  after  very  difficult  labors.  She  had  an  ovarian 
dermoid  fixed  to  the  pelvic  floor  by  dense  adhesions.  The  patient  recovered 
and  afterward  bore  a  living  child  by  normal  labor.126  He  also  reports  a  case 
in  which  repeated  abortion  had  occurred,  which  was  terminated  by  the 
removal  of  an  ovarian  cyst.  Sutton  urges,  and  we  think  rightly,  the  impor- 
tance of  removing  all  tumors  of  the  ovary  complicating  pregnancy,  before 
delivery.  Before  the  fourth  month  of  pregnancy  single  or  double  ovariotomy 
is  attended  with  very  low  mortality  and  very  little  risk  of  disturbing  the 
pregnancy.  After  the  fourth  month  the  risk  is  that  of  an  ordinary  ovari- 
otomy, but  the  chance  of  abortion  increases  with  each  month.  Cases  are  on 
record  in  which  the  removal  of  the  tumor  has  been  successfully  performed 
during  labor,  the  case  being  terminated  by  delivery  by  forceps  or  by  Cesarean 
operation. 

Observation  of  pregnant  patients  shows  that  after  delivery  an  ovarian 
tumor  which  had  been  situated  upon  one  side  of  the  abdomen  usually 
becomes  central  in  position.  This  change  of  position  usually  leads  to  the 
recognition  of  tumors  in  some  instances  for  the  first  time.  Thus  in 
Edward's  case,127  after  her  second  labor,  the  patient  noticed  for  the  first  time 
an  ovarian  tumor  which  had  been  present  for  some  time,  and  which  had 
complicated  both  parturitions. 

Fenger128  describes  the  case  of  a  primipara  who  had  had  several  attacks 
of  sudden  pain  with  chilly  sensations  occurring  during  her  first  pregnancy. 
On  examination  a  pelvic  tumor  was  found  beside  the  uterus.  The  ovarian 
growth  was  immovably  fixed  in  a  small  pelvis.  It  was  removed  by  abdom- 
inal section,  the  uterus  being  wrapped  in  warm  aseptic  cloths  soaked  in 
sterile  water  and  drawn  to  one  side  while  the  tumor  was  removed.  The 
patient's  convalescence  was  interrupted  by  occasional  uterine  pains,  which 
were  controlled  by  morphin.  The  patient  went  to  term,  and  was  delivered 
by  forceps  of  a  living  child.  Excessive  pigmentation  of  the  scar  occurred, 
which  gradually  faded  after  delivery.  Engstrom  129  reports  seven  ovarioto- 
mies during  pregnancy,  with  no  deaths.  He  collected  forty-one  additional 
cases,  with  two  deaths,  making  forty-eight  in  all,  with  but  two  deaths. 
He  makes  his  incision  as  near  the  tumor  as  possible,  so  as  not  to  disturb 
the  uterus  and  to  avoid  making  traction  upon  the  pedicle,  which  might 
lead  to  uterine  contractions.  The  abdominal  wound  is  closed  with  great 
care.  The  uterus  is  left  uncovered  as  little  as  possible,  and  a  bandage  is 
worn  for  several  months  after  the  operation.  He  gives  opium  to  prevent 
abortion. 

A  somewhat  different  view  of  the  treatment  of  these  cases  is  given  by 
Hohl.13"    Should  an  ovarian  tumor  be  discovered  during  pregnancy,  he  would 


THE   PATHOLOGY   OF  PREGNANCY.  211 

remove  it  as  soon  as  possible.  If  the  tumor  was  intraligamentous  or  firmly 
adherent,  so  that  an  operation  would  be  difficult,  he  would  produce  thera- 
peutic abortion.  Under  no  circumstances  would  he  puncture  the  tumor.  In 
the  presence  of  labor  complicated  by  an  ovarian  tumor  he  would  replace  it 
if  possible  under  anesthesia.  If  this  does  not  succeed,  he  would  puncture  or 
make  a  vaginal  incision.  In  case  of  solid  tumors  when  the  child  is  living 
Cesarean  section  and  ovariotomy  are  indicated.  The  latter  may  be  postponed 
until  the  puerperal  condition,  if  necessary.  It  is  not  considered  wise  to  per- 
form ovariotomy  only  during  labor.  Operation  during  the  puerperal  period 
should  not  be  later  than  the  second  week. 

The  diagnosis  of  ovarian  tumor  and  pregnancy  may  be  difficult.  McCone 131 
reports  the  case  of  a  primipara  who  for  three  years  had  suffered  from  nausea 
and  vomiting,  swelling  of  the  feet  and  legs,  and  enlarged  abdomen.  Nearly 
two  gallons  were  withdrawn  from  her  abdomen  by  tapping.  Eight  months 
later  her  symptoms  returned,  but  were  considerably  relieved  by  medicinal 
treatment.  Symptoms  of  pregnancy  developed,  and  the  abdomen  rapidly 
enlarged,  so  that  respiration  was  very  difficult.  Examination  of  the  abdo- 
men was  without  result,  except  to  show  that  it  was  much  enlarged,  elastic, 
and  fluctuating.  No  evidence  of  fetal  life  could  be  detected.  The  cervix, 
vagina,  and  vulva  presented  the  usual  appearance  of  pregnancy.  The  urine 
was  normal.  Upon  opening  the  abdomen  a  quantity  of  ascitic  fluid  escaped. 
A  thin-walled  multilocular  ovarian  cyst,  weighing  eighteen  and  three-quarters 
pounds,  was  then  removed,  and  the  uterus  found  enlarged  at  six  months'  preg- 
nancy. The  patient  went  to  term,  and  three  months  later  was  delivered  in 
normal  labor  of  a  full-term  child.  Her  recovery  was  without  complications. 
•  That  a  severe  and  prolonged  operation  need  not  result  in  the  interruption 
of  pregnancy  is  well  illustrated  by  Byford's  case.132  His  patient  was  four 
months  pregnant,  and  had  a  dermoid  cyst  in  the  right  iliac  and  umbilical 
l'egion,  completely  embedded  in  old  organized  peritoneal,  omental,  and 
intestinal  adhesions.  The  cyst-wall  broke  and  emptied  fluid  with  fecal  odor 
and  of  the  color  and  consistence  of  pus  into  the  abdomen.  The  pedicle  was 
long,  and  was  tied  about  an  inch  from  the  uterus.  The  abdominal  cavity 
was  flushed  with  hot  water.  Two  glass  drainage-tubes  were  used,  removed 
in  forty  hours  after  the  operation.  Uterine  contractions  occurred  afterward, 
but  were  controlled  by  morphin.  The  abdominal  wall  was  very  fat,  and  the 
peritoneum  and  fascia  only  were  closed,  the  fatty  tissue  being  allowed  to  heal 
as  an  open  wound,  being  dressed  by  dry,  aseptic  cotton  only.  No  suppura- 
tion occurred.  The  operation  lasted  two  hours,  and  was  unusually  difficult 
and  severe.  The  patient  made  a  good  recovery  with  uninterrupted  preg- 
nancy. 

Double  ovariotomy  during  pregnancy  may  be  performed  without  abor- 
tion. Mainzer133  removed  two  ovarian  tumors  from  a  primipara  four 
months  pregnant.  The  patient  had  suffered  greatly  from  pain  in  the  sacral 
'region.  The  tumors  were  upon  each  side  of  the  pelvis,  and  upon  operation 
were  found  to  be  ovarian.     The  patient  recovered  and  went  to  full  term. 


212  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

Isirne134  lays  stress  upon  the  difficulties  of  diagnosis  in  pregnancy  com- 
plicated by  ovarian  tumors,  and  calls  attention  to  the  fact  that  pregnancy 
hastens  the  growth  of  the  tumor,  and  causes  twisting  of  the  pedicle  and  the 
formation  of  adhesions.  Pregnancy  often  stimulates  the  development  of 
simple  ovarian  cysts  with  thin  walls.  Hall 135  reports  the  case  of  a  multi- 
para who  had  a  tumor  weighing  twenty-five  pounds  with  contents,  the  solid 
portion  weighing  three  and  a  half  ounces.  It  developed  very  rapidly  with- 
out adhesions  during  the  patient's  pregnancy  and  was  successfully  removed. 
Abortion  was  prevented  by  the  use  of  opium.  Kreutzmann 136  reports  a 
case  of  pregnancy  at  the  second  month,  in  which  a  cyst  of  the  right  ovary  as 
large  as  a  fetal  head  at  term  descended  into  the  pelvis  in  front  of  the  uterus. 
It  was  successfully  removed  by  section.  The  scar  after  this  operation  was 
broad,  dark  blue  in  color,  and  caused  itching  and  burning  during  pregnancy. 
The  scar  faded  after  the  patient's  recovery.  He  also  reports  a  case  of  preg- 
nancy at  the  second  month  with  an  ovarian  cyst  of  the  left  side  reaching 
almost  to  the  umbilicus.  This  was  successfully  removed,  although  it  was 
necessarv  to  tap  the  cyst  before  it  could  be  delivered  through  the  abdominal 
incision. 

Disorders  of  the  vulva  may  occur  during  pregnancy  as  the  result  of  me- 
chanical injury  or  be  associated  with  some  constitutional  condition.  Hematoma 
of  the  vulva  is  especially  likely  to  happen  by  reason  of  the  congested  condi- 
tion of  the  parts  caused  by  pregnancy.  An  illustrative  case  is  reported  by 
Ehrendorfer.137  Incision  under  antiseptic  precautions  and  tamponing,  pref- 
erably with  iodoform  gauze,  resulted  in  speedy  cure.  Pruritus  of  the  vulva 
is  one  of  the  most  annoying  complications  of  the  pregnant  condition.  In  cases 
in  which  there  is  no  reason  to  suspect  the  neglect  of  cleanliness,  pruritus 
is  to  be  considered  as  due  to  one  of  two  classes  of  causes.  The  first  class 
comprises  the  many  diseases  which  alter  profoundly  the  condition  of  the 
skin  ;  chief  among  these  are  disorders  of  the  digestive  and  excretory  sys- 
tems, as  diabetes  and  nephritis.  The  treatment  of  the  pruritus  in  such  cases 
resolves  itself,  first,  into  the  treatment  of  the  general  condition,  and  then 
into  such  local  applications  as  may  be  found  of  use.  The  latter  embraces 
the  various  antiseptics  and  anesthetics  which  are  available  in  the  practice  of 
dermatology.  The  second  class  is  those  cases  in  which  no  diseased  condition 
of  the  general  organism  can  be  found  to  account  for  the  pruritus,  and  in 
which  the  disorder  is  purely  local.  This  class  is  treated  by  local  applica- 
tions, and  in  obstinate  cases  resection  of  the  diseased  tissues  may  prove  the 
only  alternative.  Sanger  has  shown  that  in  these  cases  partial  or  total  extir- 
pation of  the  vulva  is  thoroughly  legitimate,  and  should  include  the  removal 
of  the  glans  clitoridis.  Where  the  entire  vulva  is  affected  plastic  operation 
may  be  necessary  to  cover  surfaces  exposed  in  the  extirpation.  In  circum- 
scribed pruritus  of  the  vulva  it  may  be  possible  to  limit  the  extirpation  to 
the  affected  part. 

Elephantiasis  of  the  labia  may  complicate  pregnancy,  and  prove  an' 
annoyance  to  the  obstetrician  at  the  time  of  labor.     The  appended  illustra- 


THE   PATHOLOGY   OF  PliEGXAXCY. 


213 


tion  (Fig.  144)  is  taken  from  a  case  under  the  observation  of,  and  described 
by,  the  writer.  The  patient,  who  was  pregnant  for  the  first  time,  gave  no 
history  of  venereal  disease ;  the  growth  persisted  for  several  months  before 
the  occurrence  of  pregnancy,  and  increased  slowly  during  gestation.  Aside 
from  its  bulk  it  occasioned  no  suffering.  During  labor  it  rendered  thorough 
vaginal  examination  difficult,  and  at  the  moment  of  delivery  impeded  some- 
what the  dilatation  of  the  birth-canal.  Especial  precautions  were  taken  to 
maintain  the  parts  in  an  antiseptic  condition  at  the  moment  of  delivery. 
The  patient's  convalescence  was  uninterrupted,  as  no  serious  wound  of  the 
hvpertrophied  tissue  occurred  during  the  labor.  During  the  puerperal  period 
the  injured  tissue  decreased  very  slightly  in  size. 


144.— Elephantiasis  of  the  labia  i  one-fourth  life  size 


The  presence  of  bacteria  in  the  genital  tract  of  the  healthy  pregnant 
patient  is  an  interesting  phenomenon  which  has  occasioned  extensive  research. 
The  results  go  to  show  that  pathogenic  bacteria  are  not  present  in  the 
healthy  pregnant  patient.  Among  the  most  thorough  of  such  investiga- 
tions are  those  of  Winter,138  made  at  the  suggestion  of  Schroeder  :  he  found 
that  the  Fallopian  tubes  contained  normally  no  micro-organisms  :  this  is  also 
true  of  the  normal  uterine  cavity.  In  half  the  uteri  examined  germs  were 
present  at  the  internal  os ;  in  the  secretion  of  the  cervix,  and  also  in  the 
vagina,  there  were  found  abundant  micro-organisms.  These  germs  were 
found  to  be  pathogenic,  but  not  possessing  the  virulence  which  characterizes 
them  when  observed  amid  tissues  in  a  pathologic  condition.  It  Mas  found, 
however,  that  when  pathogenic  organisms  were  introduced  from  without, 
the  germs  already  present  in  the  genital  canal  assumed  a  virulent  character. 

In  no  subject  recently  studied  have  results  so  apparently  conflicting  been 
obtained  as  in  that  of  bacteria  of  the  birth-canal  during  pregnancy.  The 
percentage  of  cases  in  which  streptococci  have  been  found  before  labor  has 


214  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

varied  with  different  observers  from  4  to  27.  "Williams1311  explains  these 
discrepancies  by  differences  in  technic  and  methods  employed  for  obtaining 
the  lochial  discharge  from  various  portions  of  the  birth-canal.  His  review 
of  the  work  of  different  observers,  and  his  own,  lead  him  to  believe  that  the 
genital  canal  of  the  healthy  patient  does  not  contain  before  labor  actively 
pathogenic  bacteria,  and  hence  that  vaginal  examinations  may  be  a  means  of 
infection  if  made  without  antiseptic  precautions,  while  vaginal  douches  are 
not  indicated  and  are  harmful.  Hoftneier,140  Kronig,141  "Walthard,142  Menge 
and  Kronig,143  144  Doderlein,145  Frederick,146  and  Kottmann,147  have  all  con- 
tributed interesting  and  valuable  papers  upon  this  subject. 

Sticher148  calls  attention  to  the  fact  that  a  pregnant  patient  may  introduce 
bacteria  into  the  vagina  by  bathing  in  a  tub  tilled  with  water  which  contains 
bacteria. 

It  is  evident  that  clinical  observation  must  supplement  the  demonstrations 
of  the  laboratory  in  giving  us  accurate  information  regarding  the  significance 
of  bacteria  within  the  genital  canal  before  and.  after  labor.  As  we  should 
naturally  expect,  the  bacteriologist  does  not  find  streptococci  within  the 
healthy  uterus  after  parturition.  The  vagina  lined  with  mucous  membrane 
resembling  the  integument  covering  the  vulva  often  contains  before  and  after 
labor  the  micro-organisms  commonly  found  about  the  vulva.  These  are  not 
actively  virulent,  and  unless  introduced  in  considerable  quantities  to  the 
lymphatics  through  lesions  in  the  tissues  they  are  not  actively  harmful.  The 
constant  danger  lies  in  the  fact  that  by  examination  or  manipulation  the  pro- 
tecting epithelia  of  the  vagina  or  cervix  will  be  wounded,  and  that  strepto- 
cocci may  be  introduced  from  without  through  these  wounds,  or  that  the 
non-pathogenic  bacteria  of  the  vagina  may  be  carried  into  the  lymphatics 
and  there  become  actively  pathogenetic.  Laboratory  research  and  clinical 
observation  agree  in  forbidding  preliminary  vaginal  douching  in  healthy 
women,  in  insisting  upon  thorough  antiseptic  precautions  before  vaginal 
examinations,  in  demanding  the  same  aseptic  technic  which  is  practised  in 
surgical  operations  upon  the  cervix  and  external  genitals  for  obstetric  opera- 
tions made  through  the  vagina.  During  the  puerperal  period  vaginal 
douches  are  dangerous,  because  of  the  liability  that  germs  from  the  vagina 
may  be  carried  into  the  uterus.  Frequent  washing  out  of  the  womb  in 
septic  cases  is  unjustifiable  and  productive  of  harm.  When  there  is  evi- 
dence that  the  vagina  has  been  the  seat  of  a  septic  process  during  preg- 
nancy, it  must  be  disinfected  as  thoroughly  as  possible  before  labor.  Unless 
the  genital  tract  during  pregnancy  is  the  seat  of  infection,  interference 
should  be  limited  as   much  as  possible  in  the  conduct  of  labor. 

Diseased  conditions  of  the  vagina  occasionally  complicate  the  pregnant 
condition  ;  thus,  Bissman 14'-'  reports  a  case  in  which  a  polypoid  degeneration 
of  the  connective  tissue  of  the  vaginal  wall  attained  such  proportions  as  to 
prolapse  before  the  fetal  head  during  labor,  and  to  offer  an  obstacle  to 
delivery  ;  in  this  case  the  condition  was  accompanied  by  gonorrheal  infec- 
tion. 


THE   PATHOLOGY   OF  PREGNANCY.  215 

Vesicovaginal  fistula  caused  by  pressure  in  a  previous  labor  may  become 
a  serious  complication  at  labor,  by  reason  of  the  thickened  condition  of  the 
tissues  about  the  fistula  and  the  excessive  paiu  which  pressure  occasions.150 

Vaginal  enterocele  may  develop  during  pregnancy,  and  is  a  condition  not 
devoid  of  danger.  Injury  to  the  intestine  and  occlusion  with  peritonitis 
may  result ;  or  the  enterocele  may  rupture  during  pregnancy  and  the  intes- 
tine protrude.  Hirst I51  reports  a  case  in  which  the  contents  of  the  sac  were 
adherent  to  the  hernia-ring  and  reduction  was  impossible.  The  patient  was 
kept  in  bed  for  a  number  of  weeks  until  premature  delivery  took  place.  It 
was  necessary  to  use  very  active  purgation  to  empty  the  bowels,  and  to  wash 
out  the  bladder  several  times  a  day  on  account  of  cystitis.  At  labor  the 
sac  was  distended  almost  to  the  bursting  point,  and  the  delivery  of  the  child 
was  very  difficult.  Had  the  patient  gone  to  term,  Cesarean  section  would 
have  been  necessary. 

Displacements  of  the  pregnant  uterus  are  not  infrequent,  often  causing 
great  discomfort,  and  sometimes  seriously  complicating  and  even  terminating 
pregnancy.  If  the  patient  has  already  borne  children,  the  supports  of  the 
uterus  are  frequently  so  weakened  that  when  repeated  pregnancy  ensues  dis- 
placement readily  occurs. 

The  most  frequent  uterine  displacement  complicating  pregnancy  is  retro- 
version of  the  gravid  uterus ;  this  produces  the  usual  symptoms — pain  and 
dragging  sensation  in  the  back,  interference  with  the  functions  of  the  rectum 
and  of  the  bladder,  and  a  sensation  of  weight  and  heaviness  relieved  only 
by  the  recumbent  position  upon  the  side  or  the  assumption  of  the  knee- 
chest  position.  On  vaginal  examination  the  os  and  cervix  are  found  directed 
upward  and  forward,  and  the  fundus  of  the  uterus  is  below  the  promontory 
of  the  sacrum.  In  uncomplicated  cases,  in  which  no  peritoneal  adhesions  exist 
binding  down  the  uterus,  retroversion  of  the  pregnant  womb  is  a  compara- 
tively simple  matter.  As  the  uterus  increases  in  size  the  womb  gradually 
rises  in  the  pelvis,  until  at  four  or  five  months  it  passes  above  the  brim  and 
remains  permanently  in  the  abdominal  cavity. 

The  treatment  of  uncomplicated  retroversion  of  the  pregnant  uterus  con- 
sists in  supporting  the  womb  by  tampons  of  antiseptic  wool  smeared  with  an 
antiseptic  ointment.  A  preparation  containing  10  grains  of  powdered  boric 
acid  to  the  half  ounce  each  of  lanolin  and  vaselin  is  most  useful  in  these 
cases.  Once  in  four  or  five  days  such  a  tampon  should  be  removed,  and  the 
vagina  be  irrigated  gently  with  warm  water  or  with  a  saturated  solution  of 
boric  acid.  A  Sims  speculum  should  then  be  used,  and  the  pelvic  floor  be 
drawn  downward  and  backward,  when  a  tampon  of  antiseptic  wool,  rolled 
into  a  shape  fitting  the  pelvic  floor,  should  be  introduced  and  carried  across 
from  side  to  side,  putting  the  uterosacral  ligaments  slightly  upon  the  stretch 
and  raising  the  fundus  of  the  uterus.  Such  tampons  have  the  great  advan- 
tage over  the  hard-rubber  pessary  that  they  create  no  irritation,  support  the 
uterus  comfortably,  and  mould  themselves  perfectly  to  the  contour  of  the 
parts.     Their  use,  however,  requires  discrimination  in   fitting  the  tampon 


216  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

properly,  and  call*  for  regular  supervision  of  the  physician  at  comparatively 
frequent  intervals.  Cases  are  occasionally  met  with  in  which  it  is  impossible 
for  the  patient  to  have  the  services  of  a  physician  except  at  intervals  of  several 
weeks.  It  is  then  often  advantageous  to  fit  a  carefully  moulded  hard-rubber 
pessary  which  raises  the  uterus  to  its  proper  level.  It  is  often  asserted  that 
such  a  pessary  may  cause  abortion ;  the  fact,  however,  remains  that  it  is  not 
a  well-fitting  pessary  that  produces  abortion,  but  it  is  the  displacement  of  the 
uterus  resulting  from  a  lack  of  such  support  as  the  pessary  should  give.  Cases 
of  habitual  abortion  caused  by  displacement  of  the  womb  are  not  infrequently 
cured  by  raising  the  pregnant  womb. 

Many  cases  of  retroversion  of  the  uterus  are  associated  with  chronic 
pelvic  peritonitis,  and  are  complicated  by  prolapse  of  one  or  both  of  the  Fal- 
lopian tubes  and  of  the  ovaries,  and  the  presence  of  adhesions  binding  the 
displaced  organs  in  their  artificial  situation.  With  these  patients  the  pain  as 
the  uterus  increases  in  size  is  very  distressing,  and  results  from  traction  upon 
adhesions ;  these  occasionally  yield,  greatly  adding  to  the  patient's  comfort. 
In  other  cases  the  separation  of  these  peritoneal  adhesions  is  accompanied  by 
very  considerable  shock,  which  simulates  to  some  extent  the  shock  of  rupt- 
ure of  the  sac  in  tubal  ectopic  gestation.  In  still  other  cases  these  adhesions 
are  so  firm  and  tense  that  spontaneous  separation  of  them  is  impossible,  the 
womb  remaining  fixed  in  the  position  it  occupied  at  the  time  of  the  original 
peritoneal  inflammation.  The  continued  growth  of  the  uterus  may  so  stretch 
these  adhesions  as  to  enable  the  womb  to  rise  into  the  abdominal  cavity. 
Should  the  peritoneal  surfaces  not  yield,  however,  a  retroverted  and  incar- 
cerated uterus  will  be  the  result,  and,  as  the  fetus  increases  in  size,  the  adhe- 
sions not  yielding,  abortion  is  inevitable;  and  should  fresh  septic  infection 
occur  and  the  patient  survive,  her  condition  will  be  aggravated  by  fresh 
adhesions,  and  chronic  invalidism  will  result. 

The  frequency  of  this  complication  may  be  estimated  by  the  report  of 
Martin,152  who  found  in  24,000  women  121  cases  of  retroversion  and  retro- 
flexion of  the  uterus  persisting  during  pregnancy.  In  27  of  these  cases  the 
deformity  was  congenital,  and  1  case  is  cited  in  which  a  patient  suffered  for 
three  and  a  half  years  with  congenital  retroflexion  and  with  gonorrhea,  but 
conceived  after  recovery  from  the  gonorrhea.  Sterility  in  cases  of  congeni- 
tal retroflexion  depends  upon  a  diseased  endometrium  or  diseased  condition 
of  the  tube,  and  not  upon  the  congenital  deformity.  In  94  of  the  cases  the 
retroversion  persisted  after  repeated  pregnancies.  Nine  of  these  patients 
wore  pessaries  at  the  time  conception  occurred.  The  most  significant 
symptom  which  drew  the  patient's  attention  to  the  backward  displacement 
of  the  uterus,  and  for  which  she  sought  medical  aid,  was  dysuria.  When 
spontaneous  restitution  fails  no  time  should  be  lost  in  accomplishing  the 
same  by  instrumental  means.  That  retroflexion  and  incarceration  of  the 
pregnant  uterus  are  a  serious  condition  may  be  inferred  from  the  report  and 
collection  by  Treub  of  50  cases  of  death  from  this  cause.153  He  found  that 
out  of  the  50  deaths,  13  were  from  uremia,  11  from  rupture  of  the  bladder 


THE   PATHOLOGY   OF   PREGNANCY. 


217 


(Fig.  145),  6  from  sepsis  ;  10  followed  peritonitis  and  cystitis  ;  3  were  caused 
by  pyemia,  2  by  rupture  of  the  peritoneum,  and  5  cases  followed  accidents 
occurring  during  an  effort  to  replace  the  uterus. 

These  statistics  have  recently  been  amplified  by  Gottschalk,154  who  collected 
67  deaths  from  backward  displacements  of  the  pregnant  uterus,  the  imme- 
diate causes  of  which  he  describes  as  follows  :  Uremia  and  collapse,  16  cases  ; 
septicemia  arising  from  the  bladder,  4 ;  gangrene  of  the  bladder,  3  ;  rupture 
of  the  bladder,  11;  peritonitis  from  disease  of  bladder,  17;  pyemia,  3; 
rupture  of  the  peritoneum  and  vagina,  2  ;  improper  efforts  at  reposition,  5 ; 
gangrene  of  the  intestine  and  peritonitis,  1  ;  occlusion  of  the  intestine,  1  ;  and 
4  cases  in  which  the  immediate  cause  of  death  is  not  described.  Gottschalk 
in  his  paper  reports  an  interesting 
case  under  his  own  observation,  in 
which  the  retroverted  pregnant  uterus 
produced  intestinal  occlusion  without 
ileus.  He  performed  abdominal  sec- 
tion, but  was  unable  to  save  the 
patient. 

Ectopic  gestation  may  be  simulated 
by  a  retroverted  pregnant  uterus,  as 
in  a  case  reported  by  Barbour,13,5  in 
which  the  physical  signs  of  retrover- 
sion in  the  pregnant  uterus  were  per- 
fectly present.  In  the  treatment  of 
this  condition  Cohnstein,106  in  five 
severe  cases  of  incarceration  of  the 
pregnant  uterus,  first  emptied  the 
bladder  by  a  stiff  catheter,  and  then 
drew  down  the  cervix  and  vaginal 
wall  with  a  tenaculum,  while  the  cer- 
vix was  pressed  backward  by  down- 
ward pressure  behind  the  symphysis. 
"While  the  cervix  was  drawn  down- 
ward and  backward  by  a  tenaculum  the  fundus  was  raised  with  the  free 
hand  of  the  operator. 

Eetroversion  of  the  pregnant  uterus  is  occasionally  found  complicated  by 
the  existence  of  disease  of  the  pelvic  bones ;  in  these  cases  the  pelvic  de- 
formity is  often  such  that  spontaneous  restitution  of  the  uterus  is  impossible. 
It  is  then  necessary  to  relieve  the  patient  by  operative  means,  and,  as  a  last 
resort,  to  extirpate  the  uterus  per  vaginam  if  possible.  An  interesting  case 
of  osteomalacia  complicating  retroflexion  of  the  gravid  uterus  is  reported  by 
Benckiser  ;157  efforts  had  previously  been  made  to  produce  abortion  and  to 
puncture  the  fetal  sac  through  the  posterior  vaginal  wall. 

The  treatment  of  retroversion  of  the  pregnant  uterus  when  adhesions  are 
present  must  be  conducted  with  great  caution.     A  gentle  effort  should  be 


Fig.  145.— Frozen  section  of  retroverted  uterus 
of  three  and  a  half  to  four  months.  Death  from 
rupture  of  bladder  {Arch.}.  Gyn.,  Band  41,  Taf.  8,  f.  1). 


218  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

made  to  stretch  the  adhesions,  gradually  allowing  the  womb  to  regain  its 
lost  position  ;  this  is  best  accomplished  by  the  use  of  the  antiseptic  wool  tam- 
pon, combining  with  it  an  alterative  application  which  shall  aid  in  the  absorp- 
tion of  exudates  in  the  pelvis  and  shall  loosen  adhesions.  At  present  a 
favorite  remedy  for  this  purpose  is  ichthyol,  as  follows  : 

I$s      Ichthyol,  1  dram ; 

Lanolin, 
Vaselin,  aa  li  drams. 

An  ointment  stronger  in  ichthyol  is  occasionally  employed  with  good  results. 
Once  or  twice  weekly  the  patient  may  take,  with  advantage,  a  hot  vaginal 
injection  if  this  be  practised  very  gently.  In  cases  of  sudden  and  severe 
abdominal  pain  with  great  shock,  occurring  in  patients  in  the  early  months 
of  pregnancy  and  with  retroverted  uteri,  prompt  incision  of  the  abdomen, 
with  assiduous  examination  of  the  pelvic  organs,  may  result  in  finding  a 
small  focus  of  infection  or  a  ruptured  adhesion  which  can  be  dealt  with  suc- 
cessfully by  surgical  means.  If  such  adhesions  do  not  yield,  abortion  is 
inevitable,  and  especial  precautions  must  be  taken  that  septic  infection  is  pre- 
vented in  uteri  so  bound  down. 

The  fact  that  hematosalpinx  or  pyosalpinx  very  frequently  accompanies 
such  peritoneal  adhesions  indicates  the  danger  of  rupture  of  such  accumula- 
tions and  of  acute  septic  infection  which  may  follow.  If  such  rupture 
occurs,  evidenced  by  pain  in  .the  abdomen  and  symptoms  of  shock,  the  abdo- 
men should  be  opened  at  once,  the  parts  be  carefully  inspected  while  the 
patient  is  in  the  Trendelenburg  posture,  and  all  foci  of  infection  should 
thoroughly  and  completely  be  removed.  With  free  irrigation  with  saline 
fluid  and  drainage  it  is  possible  that  such  a  patient  may  escape  general  infec- 
tion of  the  abdominal  cavity. 

Giles158  calls  attention  to  the  resemblance  between  retroversion  of  the 
pregnant  uterus  and  ectopic  gestation.  If  such  confusion  arises,  the  patient 
should  be  kept  under  observation,  the  physician  standing  in  readiness  to 
interfere  at  any  time  should  dangerous  symptoms  appear.  When  the  pregnant 
uterus  is  bound  down  in  the  hollow  of  the  sacrum,  the  operator  must  choose 
between  inducing  abortion  and  opening  the  abdomen  and  freeing  the  uterus. 
AVhen  the  parents  consent  to  the  effort  to  save  the  fetus,  this  latter  course 
should  be  selected. 

Sinclair,159  at  a  meeting  of  the  Obstetrical  Society  of  London,  reported 
fifteen  cases  in  which  he  had  successfully  secured  replacement  of  a  retroverted 
pregnant  uterus  by  having  the  patient  lie  upon  her  side  with  her  hips  raised, 
a  watch-spring  pessary  having  been  introduced.  In  the  discussion  of  this 
paper,  Doran  described  a  case  in  which,  three  days  after  reduction  of  the  uterus, 
the  patient  aborted  and  died  from  sepsis,  the  mucous  membrane  of  the  bladder 
sloughing  away.  He  also  drew  attention  to  a  case  in  which  the  urachus  had 
been  forced  open  by  the  retroverted  pregnant  uterus,  which  prevented  the 
emptying  of  the  bladder.     He  spoke  of  the  confusion  in  diagnosis  between 


THE  PATHOLOGY   OF  PREGNANCY.  219 

retroverted  pregnant  uterus  and  a  fibroid  in  the  posterior  wall  of  the  uterus. 
Galabin  relied  upon  immediate  taxis,  and  often  without  anesthesia.  He 
rarely  failed  by  this  method.  A  case  of  Matthews  Duncan  was  also  described 
in  which  it  was  impossible  to  replace  the  retroverted  pregnant  uterus,  and  in 
which  abortion  was  induced.  Ulceration  at  the  umbilicus  supervened,  and 
offensive  urine  was  discharged  at  this  point.  At  autopsy  the  mucous  mem- 
brane of  the  bladder  had  almost  entirely  disappeared,  and  the  sinus  extended 
from  the  bladder  to  the  umbilicus. 

Kerr100  described  before  the  Obstetrical  Society  of  London  four  cases  of 
l-etroversion  of  the  pregnant  uterus,  one  of  which  terminated  in  spontaneous 
l'eplacement.  One  was  a  case  operated  upon  by  Cameron,  who  opened  the 
abdomen,  performed  cystotomy,  emptied  the  bladder  of  a  large  quantity  of 
blood-clot,  replaced  the  uterus,  and  stitched  up  the  bladder  and  abdomen. 
The  pregnancy  continued  to  full  term.  A  third  case  was  partial  retroversion 
of  the  pregnant  uterus  caused  by  a  myoma  in  the  anterior  wall.  The  uterus 
was  replaced  and  the  pregnancy  continued.  In  the  fourth  case,  ectopic  preg- 
nancy was  mistaken  for  a  retroflexed  pregnant  uterus. 

Doran,  in  discussion,  drew  attention  to  a  case  in  which  for  some  days  it 
was  impossible  to  distinguish  between  ectopic  gestation  and  retroverted  preg- 
nant uterus.  Very  gentle  examination  was  practised,  and  a  diagnosis  finally 
established.  Seeligmann  Il!1  reports  four  cases  of  incarceration  of  the  retro- 
verted pregnant  uterus,  one  of  which  was  that  of  a  patient  aged  forty-three, 
in  whom  the  uterus  had  been  secured  by  vagino-fixation  two  years  previously. 
One  of  these  cases  was  that  of  a  patient  aged  thirty-five,  who  had  a  peri- 
metritis and  retroflexion,  and  who  became  pregnant.  The  urine  was  highly 
offensive,  and  the  fundus  of  the  uterus  incarcerated  beneath  the  promontory 
of  the  sacrum.  In  addition,  the  patient  had  a  heart  lesion  which  made  the 
use  of  anesthetics  dangerous.  She  was  put  in  the  dorsal  position,  the  cervix 
drawn  strongly  downward  and  to  the  left,  and  the  fundus  uteri  carried 
stronglv  to  the  right  and  above.  The  patient  was  then  turned  upon  her  right 
side,  and  a  kolpeurynter  introduced  and  carried  backward  on  the  right  side, 
and  filled  with  a  solution  of  boric  acid.  This  was  allowed  to  remain  two 
hours  and  a  half,  when  strong  pains  in  the  pelvis  supervened,  and  after 
another  two  and  a  half  hours  the  kolpeurynter  was  emptied.  The  following 
morning  the  fundus  was  found  considerably  higher,  and  on  the  day  follow- 
ing it  was  possible  to  replace  the  uterus  with  bimanual  manipulation.  The 
pregnancy  was  not  interrupted.  Those  who  believe  that  abdominal  section 
is  the  safest  method  of  dealing  with  these  cases  will  find  support  in  the  cases 
reported  by  Mouchet.162  He  reports  two  cases,  the  first  of  which  was  three 
and  a  half  months  pregnant,  with  the  uterus  incarcerated,  complete  retention 
of  urine,  and  great  pain.  Other  methods  failing  and  the  retention  of  urine 
being  absolute,  abdominal  incision  was  made  and  the  uterus  found  not  adher- 
ent, but  completely  filling  the  concavity  of  the  sacrum.  The  hand  was  cau- 
tiously introduced  and  the  uterus  brought  out  of  the  pelvis  into  its  usual 
position.     The  result  was  entirely  satisfactory,  the  patient  going  to  full  term. 


220  AMERICA N    TEXT- BOOK    OF    OBSTETRICS. 

His  second  case  was  that  of  a  retroversion  of  the  pregnant  uterus  at  four 
months,  complicated  by  ovarian  cyst  and  incarceration.  An  attempt  was 
made  to  push  the  tumor  out  of  an  unfavorable  position  by  making  pressure 
through  the  vagina  and  through  the  rectum.  It  became  very  difficult  to 
catheterize  the  patient,  and  accordingly  the  abdomen  was  opened.  A  small 
cyst  of  the  left  ovary  was  removed,  when  it  was  a  simple  matter  to  replace 
the  uterus.  The  patient  had  some  pain  afterward,  which  was  controlled  by 
morphin.     She  made  a  good  recovery  without  interruption  of  the  pregnancy. 

2.  The  Urinary  Organs  during  Pregnancy. 
The  urethra,  bladder,  and  ureters  share  during  pregnancy  the  condition 
of  increased  vascularity  and  irritability  that  characterizes  the  pelvic  organs. 
The  bladder  in  early  pregnancy  is  less  capable  of  distention  antero-poste- 
riorly,  and  hence  enlarges  laterally  as  gestation  goes  on.  In  the  later  months 
of  pregnancy  the  uterus  rises  in  the  abdomen,  drawing  the  bladder  with  it 
above  the  pelvic  brim  ;  this  seems  a  conservative  provision  to  protect  the 
bladder  from  injury  by  pressure.  The  bladder  accompanies  the  uterus  in 
the  displacements  frequently  seen  during  pregnancy.  The  urethra  becomes 
elongated  as  the  uterus  rises  in  the  pelvis.  The  urethra  may  become  com- 
pletely or  partly  occluded  in  some  of  the  uterine  displacements  observed 
during  early  pregnancy.  If  the  displacement  of  the  uterus  be  not  corrected, 
there  follow  overdistention  of  the  bladder,  paralysis  of  its  muscular  layer, 
and  decomposition  of  the  retained  urine,  with  erosion,  ulceration,  and  final 
perforation. 

Cystitis  and  hematuria  complicating  pregnancy  demand  rest  in  the  recum- 
bent posture;  and  if  the  inflammation  of  the  bladder  be  gonorrheal  in  char- 
acter, its  careful  treatment  is  strongly  indicated.  Labor  in  such  cases,  by 
making  traction  upon  pelvicf  adhesions,  may  compress  the  ureters,  favoring 
the  development  of  uremic  poisoning  and  eclampsia.  Subinvolution  of  the 
uterus  is  very  apt  to  occur  in  such  cases,  while  the  inflammation  of  the 
urinary  tract  may  become  chronic.  Diphtheritic  inflammation  of  the  bladder 
is  seen  in  cases  in  which  an  incarcerated  uterus  prevents  the  passage  of  urine, 
and  in  which  a  catarrhal  condition  of  the  mucous  membrane  has  previously 
been  present.  In  cases  in  which  during  pregnancy  the  germs  of  gonorrhea 
have  been  retained  in  and  about  the  urethra,  labor,  by  reason  of  the  pressure 
and  disturbance  of  the  parts  which  then  occur,  may  cause  migration  of  these 
germs.  Cystitis  is  the  first  result  of  such  added  infection,  and  later  this 
infection  travels  up  the  ureters  to  the  kidney,  and  acute  parenchymatous 
nephritis  may  be  the  result :  this  whole  process  occupies  several  weeks  for 
its  full  development  and  consummation,  and  its  issue  is  usually  fatal,  the 
patient  perishing  from  septicemia.1153 

The  Kidneys  during-  Pregnancy. — There  is  abundant  evidence  to  show 
that  the  kidneys  share  with  the  other  viscera  the  congested  and  hypertro- 
phied  condition  common  during  pregnancy.  This  peculiar  engorgement  of 
the  kidney  has  given  rise  to  the  term   "  kidney  of  pregnancy."     Much  dis- 


THE   PATHOLOGY   OF  PREGNANCY.  221 

cussion  has  been  elicited  in  the  effort  to  differentiate  the  "  kidney  of  preg- 
nancy" from  beginning  nephritis.  It  is  evident  that  only  the  systematic 
and  microscopic  examination  of  the  urine  can  accurately  determine  whether 
simple  congestion  is  present,  or  whether  the  kidney  is  being  damaged  in  its 
essential  elements,  the  secreting  cells  of  the  tubules.  When  such  study  of 
the  urine  finds  only  hyaline  casts,  crystals  of  various  sorts,  and  the  slight 
epithelial  debris  which  may  be  found  in  healthy  individuals,  there  is  no  rea- 
son to  believe  that  nephritis  exists ;  but  when,  on  the  other  hand,  epithelial, 
granular,  or  fatty  casts  are  persistently  present,  the  diagnosis  of  nephritis 
can  scarcely  be  denied.  It  is  upon  such  comparative  examinations  that  a 
diagnosis  must  be  based,  and  not  upon  the  mere  presence  or  absence  of  serum- 
albumin.  Attention  has  recently  been  called  by  Trantenroth  164  to  a  condi- 
tion of  beginning  fatty  degeneration  in  the  kidney  which  causes  no  symptom 
in  the  urine,  and  which  may  suddenly  become  so  acute  as  to  destroy  the 
patient  by  sudden  kidney  failure.  Infective  process  as  present  in  these  cases 
is  so  far  wanting,  and  patients  thus  affected,  if  they  survive  pregnancy,  do 
not  become  nephritic  afterward.  An  acute  inflammation  of  the  kidney  can- 
not be  caused  by  pregnancy,  and  is  only  observed  in  the  rare  cases  in  which 
infective  bacteria  find  entrance  to  the  genito-urinary  tract  of  the  pregnant. 
This  condition  of  congestion  during  pregnancy  is  increased  during  labor,  and 
renal  albumin  is  present  during  the  progress  of  labor  in  considerable  amount. 
Patients  suffering  from  diseased  kidneys  and  becoming  pregnant  have  the 
kidney  disorder  greatly  aggravated,  often  to  a  fatal  issue.  The  causes  of  this 
condition,  known  as  the  "  kidney  of  pregnancy,"  are  the  increased  intra- 
abdominal tension  to  which  all  the  viscera  are  subjected  ;  disturbances  in  the 
nutrition  of  the  kidney  through  an  altered  condition  of  the  blood  of  the  preg- 
nant patient ;  and  an  engorgement  of  the  spermatic  veins  and  ureters  by 
mechanical  pressure.  It  is  possible  for  eclampsia  to  develop  without  lesion 
of  the  kidneys,  although  in  most  cases  of  eclampsia  a  diseased  condition  of 
the  kidneys  can  plainly  be  discerned.  Fischer,  in  studying  the  same  sub- 
ject,165 found  in  70  cases  evidence  that  the  "  kidney  of  pregnancy"  was  pres- 
ent in  58  ;  8  cases  of  nephritis  occurred  among  the  70  patients.  Fischer 
found  red  blood-corpuscles  in  considerable  amount  in  cases  in  which  acute 
nephritis  occurred.  Granular  and  epithelial  casts  indicated  chronic  nephritis. 
The  occurrence  of  chronic  endarteritis  accompanying  chronic  nephritis  ex- 
plains the  rupture  of  blood-vessels  within  the  uterus  and  the  intra-uterine 
hemorrhage  which  sometimes  destroys  these  patients.  Schauta166  describes 
a  tvpical  case  of  fatal  hemorrhage  in  which  chronic  intei\stitial  nephritis  and 
defeneration  of  the  muscle  of  the  heart  and  uterus  were  found.  The  life  of 
the  child  was  also  sacrificed. 

Albuminuria  is  of  such  frequent  occurrence  during  pregnancy  as  scarcely 
to  require  serious  consideration,  except  as  a  symptom  in  connection  with 
others  of  nephritis.  Among  others,  Meyer,167  from  an  elaborate  study  of  this 
subject  at  Copenhagen,  found  albuminuria  in  5.4  per  cent,  of  pregnant  women. 
Casts  accompanied   the  albumin   in  2  per  cent.     This  may  be  taken  as  an 


222  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

indication  of  the  relative  frequency  of  kidney  involvement  in  cases  manifest- 
ing albuminuria.  As  pregnancy  advanced,  albumin  became  more  abundant, 
until  during  the  last  thirty  days  but  28.9  per  cent,  of  urine  examined  was 
free  from  albumin.  Premature  births  occurred  in  8  per  cent,  of  patients 
with  albumin,  and  in  21.5  per  cent,  of  patients  who  had  casts  in  the  urine. 
He  adds  other  clinical  details  which  emphasize  the  significance  of  the  pres- 
ence of  casts  as  indicating  nephritis.  Lantos,168  in  the  clinic  at  Budapest, 
found  albumin  so  frequently  in  pregnant  patients  that  he  considers  it  physio- 
logic during  pregnancy  and  a  diagnostic  symptom  of  the  condition.  Herman 
calls  attention  to  this,169  and  in  other  papers  presented  at  the  Obstetrical  So- 
ciety of  London,  to  two  conditions  of  renal  disease  in  the  pregnant  woman  : 
one  is  acute  kidney  failure  with  extreme  diminution  in  the  quantity  of  urine 
and  deficiency  in  the  excretion  of  urea,  which  quickly  ends  fatally  if  the 
excretion  of  urea  is  not  re-established.  The  other  process  resembles  inter- 
stitial nephritis  in  its  slow  course  and  ultimately  fatal  termination.  The 
interesting  fact  that  a  patient  may  have  uremic  convulsions  during  pregnancy 
without  eclampsia  is  illustrated  by  Boudin,170  who  describes  a  patient  seven 
months  pregnant  admitted  to  the  hospital  unconscious  with  uremic  con- 
vulsions. On  establishing  the  secretion  of  urine  and  purging  the  patient, 
consciousness  returned,  and  the  following  day  a  seven  months'  fetus  was  still- 
born. Symptoms  of  uremia  supervened,  but  recovery  finally  ensued.  The 
patient  manifested  no  symptom  of  eclampsia  and  had  no  edema.  The  very 
interesting  question  of  the  prognosis  in  nephritis  during  pregnancy  has 
recently  received  consideration  at  the  hands  of  Koblanck.1"1  In  a  series  of 
77  patients,  59.7  per  cent,  showed  nothing  pathologic  in  the  urine  after  their 
recovery  from  labor;  16.6  per  cent,  manifested  slight  involvement  of  the 
kidneys,  as  shown  by  hyaline  casts  and  leukocytes,  with  a  trace  of  albumin  ; 
in  15.4  per  cent,  a  catarrhal 'condition  of  the  urinary  tract  was  evidently 
present ;  in  6.5  per  cent,  the  patients  were  the  victims  of  nephritis.  Eklund 172 
gives  the  results  of  the  examination  of  106  patients  regarding  the  occurrence 
of  albuminuria  in  the  puerperal  condition.  He  found  that  all  of  these  had 
albuminuria  immediately  after  the  birth  of  the  child,  in  quantity  varying 
from  a  trace  up  to  1.2  per  cent,  in  one  case.  This  was  proved  to  be  the 
result  of  a  condition  of  the  kidney,  an  excessive  functional  activity,  as  the 
result  of  absorption  of  fatty  matter  in  the  process  of  involution.  Utley173 
found  among  160  pregnant  women  20  whose  urine  contained  albumin.  Of 
these  20,  15  gave  evidence  of  organic  disease  of  the  kidney.  One  had  symp- 
toms of  acute  tubular  nephritis,  4  of  chronic  tubular  nephritis,  and  in  no- 
case  was  there  evidence  of  chronic  interstitial  nephritis  or  amyloid  disease  of 
the  kidney.  In  12  of  these  20  patients  there  was  no  evidence  of  uremia. 
As  observed  in  these  cases,  albuminuria  during  pregnancy  was  a  functional 
lesion  of  little  import  regarding  the  occurrence  of  eclampsia  or  the  develop- 
ment of  an  important  lesion  in  the  kidney.  Saft m  found  albuminuria  in 
54.1  per  cent,  of  pregnant  women,  usually  in  the  second  half  of  the  preg- 
nancy.    It  persists  longer  after  labor  in  primigravidse  than  in  multigravida?, 


THE   PATHOLOGY    OF  PREGNANCY.  223 

and  kidney  lesions  are  more  serious  in  primigravidse.  Blood-corpuseles 
without  albumin  found  in  the  urine  of  pregnant  women  come  from  the  blad- 
der, while  tube-casts  accompany  albumin.  Casts  and  albumin  do  not  stand 
in  close  relation  to  each  other,  nor  do  the  amounts  of  albumin  and  casts  main- 
tain a  corresponding  ratio.  Twin  pregnancy,  hydramuios,  and  contracted 
pelvis  favor  albuminuria  in  pregnancy,  especially  in  primigravidse.  Ritchie175 
reports  a  case  of  albuminuria  with  multiple  pregnancy,  papyraceous  fetus, 
and  placenta  prsevia.  She  had  several  hemorrhages,  and  was  finally  deliv- 
ered of  a  macerated  fetus,  making  a  good  recovery.  Palmer170  calls  atten- 
tion to  the  occurrence  of  pneumonia  in  albuminuric  patients,  developing 
during  the  puerperal  period.  As  early  as  the  fourth  or  fifth  day  in  the  puer- 
peral period  such  development  is  not  infrequent. 

The  presence  of  sugar  in  the  urine  during  pregnancy  had  been  the  sub- 
ject of  investigation  by  Berberoff 177 :  his  tests  were  thorough  and  minute, 
and  his  results  were  largely  negative,  a  trace  of  sugar  being  present  in  some 
patients  in  early  pregnancy  and  disappearing  as  labor  approached.  Polyuria 
may  be  observed  in  the  pregnant  patient  without  a  pathologic  condition  of 
the  urine,  as  in  a  case  reported  by  Voituriaz.175  Among  the  most  significant 
of  the  symptoms  presented  by  pregnant  patients  suffering  from  nephritis  may 
be  reckoned  albuminuric  retinitis.  Abundant  evidence  of  the  significance 
of  this  complication  is  afforded  by  the  literature  of  ophthalmology  upon  the 
subject.  In  a  recent  paper,  Randolph  17il  reports  five  cases,  with  a  pathologic 
study  and  drawings  of  the  tissues  involved  :  he  regards  visual  disturbances 
occurring  in  the  first  six  months  of  pregnancy,  associated  with  violent  head- 
ache, as  very  significant  of  albuminuric  retinitis.  If  this  condition  be  found, 
to  save  sight,  pregnancy  should  at  once  be  terminated.  Visual  disturbances 
during  the  last  seven  weeks  of  pregnancy  are  of  less  grave  import.  The 
occurrence  of  renal  retinitis  in  one  pregnancy  does  not  necessarily  mean  its 
recurrence  in  a  succeeding  pregnancy. 

The  treatment  of  disorders  of  the  urinary  tract  occurring  during  preg- 
nancy necessitates,  first,  a  careful  examination  of  the  position  of  the  uterus, 
inasmuch  as  pressure  upon  the  bladder,  ureters,  and  kidneys  by  a  displaced 
pregnant  uterus  is  so  frequently  a  cause  of  disease.  A  retroverted  uterus 
should  be  raised  and  be  supported  in  proper  position  by  tampons  of  antisep- 
tic carded  wool.  Cystitis  may  be  treated  by  douching  the  bladder  with  creo- 
lin  or  lysol,  30  drops  to  the  pint  or  quart  of  warm  water,  as  the  patient's 
tolerance  will  permit.  The  administration  of  salol,  of  boric  acid,  or  of 
sodium  salicylate  internally  is  also  of  advantage.  If  the  ureters  become 
involved,  catheterization  of  these  ducts,  the  bladder  having  first  been  ren- 
dered aseptic,  is  indicated  to  determine  which  kidney  is  affected  if  pyelitis 
is  present.  Should  this  procedure  show  the  presence  of  pus  and  bacteria  in 
one  kidney,  the  extirpation  or  the  drainage  of  this  organ  is  indicated.  Such 
disorders,  however,  complicating  pregnancy  are  unfavorable  and  dangerous 
to  the  life  of  the  patient.  Should  recovery  occur,  the  patient  is  liable,  after 
the  birth  of  the  child,  to  become  the  victim  of  some  form  of  chronic  nephritis. 


224  AM  ERIC  AX   TEXT-BOOK    OF    OBSTETRICS. 

Suppurating-  hydatid  of  the  abdomen  is  an  infrequent  but  dangerous 
complication  of  pregnancy-  The  diagnosis  is  made  by  the  presence  of  an 
abdominal  tumor  not  attached  to  the  uterus,  and  by  the  contents  of  this 
tumor  obtained  through  tapping.  An  incision  should  be  made  through  the 
abdominal  wall,  and  the  edges  of  the  sac  of  the  tumor  be  sewn  to  the  edges 
of  the  abdominal  incision.  So  soon  as  adhesion  has  taken  place  the  cyst 
should  be  opened  and  its  contents  thoroughly  removed.  Pregnancy  is  not 
necessarily  interrupted  by  this  complication. 

Peritonitis  during-  pregnancy  ,1S0  as  has  been  stated,  results  in  most  cases 
from  previous  inflammation  of  the  endometrium,  the  Fallopian  tubes,  or  the 
connective  tissue  of  the  pelvis,  caused  by  septic  germs  or  their  spores.  There 
remain,  however,  cases  in  which  no  infection  can  be  traced,  but  in  which 
sudden  exposure  to  cold  or  to  dampness  may  produce  rapidly  extending  and 
fatal  peritonitis ;  thus,  instances  are  recorded  where  a  cold  bath  taken  while 
the  patient  was  overheated,  and  accompanied  by  the  drinking  of  cold  fluid, 
was  followed  by  rapidly  developing  and  fatal  general  peritonitis. 

Mechanical  injury  or  a  severe  strain  may  be  followed  by  peritonitis  in 
a  pregnant  patient.  Gow181  reports  the  case  of  a  patient  advanced  in  preg- 
nancy who  slipped  through  a  hole  in  the  floor  of  a  building  ;  peritonitis 
supervened ;  the  patient  was  delivered  by  version,  but  ceased  breathing  dur- 
ing delivery.  Abdominal  incision  disclosed  no  blood  in  the  peritoneal  cavity, 
but  lymph  was  found  upon  the  peritoneum  and  uterus.  No  evidence  of 
rupture  of  the  uterus  or  other  organ  was  discovered.  No  focus  from  which 
the  inflammation  could  have  begun  was  found  upon  examination.  Phillips182 
reports  the  case  of  a  patient  nearly  seven  months  pi*egnant  and  in  good 
health,  who  fell  over  a  chair-back  on  her  left  side.  She  had  great  pain  and 
persistent  vomiting.  Labor  came  on,  but  no  true  pains  could  be  distinguished, 
and  terminated  very  quickly.  She  rapidly  grew  worse  and  was  admitted  to 
a  hospital.  The  abdomen  was  opened  and  a  general  peritonitis  found  with- 
out apparent  cause.  The  patient  died  in  a  few  hours.  The  autopsy  showed 
the  lower  parts  of  both  pleurae  covered  with  soft  and  purulent  lymph ;  no 
pneumonia  present,  but  general  peritonitis  with  purulent  lymph  gluing  the 
intestines  together.  This  was  less  marked  beneath  the  wound  and  extremely 
prominent  over  the  ovaries  and  tubes.  There  was  no  rupture  of  the  stomach 
or  intestines,  no  purulent  foci  were  found  in  the  uterus,  nor  was  its  wall  per- 
forated or  damaged. 

Phillips  gives  abstracts  of  five  other  cases.  In  some,  a  blow  upon  the 
abdomen  preceded  death  ;  in  one,  the  patient  was  suspected  of  having  taken 
drugs  to  produce  abortion.  Gosset  and  Mouchotte1S3  report  the  case  of  a 
woman,  aged  twenty-six,  a  multipara,  who  had  fatal  peritonitis  at  three 
months'  pregnancy.  On  opening  the  abdomen  the  peritoneal  cavity  was 
found  containing  a  large  quantity  of  seropurulent  fluid  of  fetid  odor.  The 
source  of  infection  was  the  right  Fallopian  tube,  from  whose  opening  pus 
welled  up  upon  slight  pressure.  One  can  readily  understand  the  occurrence 
of  peritonitis  in  a  case  in  which  a  septic  focus  ruptures  into  the  abdominal 


THE   PATHOLOGY    OF  PREGNANCY.  225 

cavity.  It  is  not  so  easy  to  find  a  cause  for  peritonitis  following  a  mechan- 
ical injury  of  no  great  severity  or  some  other  non-infective  or  non-traumatic 
cause. 

Concealed  accidental  hemorrhage  is  among  the  most  dangerous  compli- 
cations of  pregnancy.  One  of  the  most  extensive  collections  of  such  cases 
is  that  by  Storer,lsi  who  contributes  an  account  of  46  in  his  own  observation, 
and  adds  the  collection  of  84  cases  by  Goodell  and  23  by  Braxton  Hicks, 
making  a  total  of  153  :  46.7  per  cent,  of  the  mothers  perished,  and  of  the 
children  94  per  cent.  died.  It  is  thus  apparent  how  insidious  is  the  danger, 
and  now  difficult  is  its  recognition  in  these  patients.  There  is  contributed 
by  Jardrin185  a  further  series  of  these  cases,  the  results  of  which  differ  in  no 
particular  from  those  observed  in  the  more  extensive  series  of  Storer.  As 
so  much  importance  naturally  attaches  to  a  diagnosis  of  this  complication,  it 
must  be  remembered  that  the  hemorrhage  is  concealed,  and  that  the  patient 
may  be  thrown  into  a  condition  of  danger  without  apparent  flow  of  blood  : 
her  symptoms  then  will  divide  themselves  into  two  classes,  namely,  those 
pertaining  to  her  general  condition,  and  those  which  have  to  do  with  the 
uterus  itself;  of  these,  the  first  furnishes  the  best  indications  of  danger  and 
the  most  rational  suggestions  for  treatment.  A  rapid,  weak  pulse,  lacking 
intension;  an  indifferent,  languid  attitude  of  mind  ;  respiration  becoming 
more  and  more  shallow  ;  a  pale  or  pallid  face  ;  a  clammy  skin  ;  thirst;  dim- 
ness of  vision,  and  "air-hunger";  a  restless  irritability  which  is  a  very  sig- 
nificant symptom  of  a  certain  kind  of  shock, — these  furnish  an  array  of 
symptoms  which  should  attract  the  attention  of  the  physician. 

If  concealed  accidental  hemorrhage  occurs  during  labor,  labor-pains  may 
cease  or  may  grow  weak,  and  the  usual  sensation  of  pain  in  the  uterus  may 
be  replaced  by  a  dull  constant  ache  above  the  pubes.  It  is  occasionally 
noticed  that  the  os  uteri  is  dilating  without  apparent  labor-pains.  The  uterus 
may  become  enlarged,  forming  an  asymmetrical  tumor  of  the  abdomen 
which  can  be  appreciated  by  palpation.  As  regards  those  symptoms  which 
can  be  observed  on  making  an  examination  of  the  genital  tract,  the  os  uteri 
is  usually  slightly  dilated  and  the  cervix  is  softened,  although  it  may  not  be 
effaced.  Slight  uterine  hemorrhage  is  generally  observed.  The  lower  uterine 
segment  becomes  distended  with  clot ;  as  the  hemorrhage  persists  the  sensa- 
tion conveyed  to  the  finger  resembles  that  in  placenta  prsevia.  Ineffectual 
and  spasmodic  uterine  contractions  and  the  accumulation  of  blood  between 
the  fetus  and  the  wall  of  the  uterus  will  cause  irregular  enlargement  of  the 
womb. 

Concealed  accidental  hemorrhage  from  some  other  source  than  the  uterus 
or  the  placenta  may  occur  during  pregnancy,  the  blood  escaping  into  the 
abdominal  cavity.  An  illustrative  case  is  reported  by  Sutuginls6  of  a  multi- 
gravida  who,  three  days  before  admission  to  the  hospital,  had  fallen  while 
carrying  a  heavy  load.  Two  days  after  her  fall  she  was  seized  with  weakness, 
and  felt  no  fetal  movments  after  this  time.  When  examined  no  dilatation 
of  the  os  and  cervix  was  present.     The  fetal  heart-sounds  were  absent.     The 


226  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

patient  complained  greatly  of  pain  in  the  uterus,  probably  caused  by  uterine 
contractions.  Shortly  after  delivery  the  patient  had  clonic  spasm  of  the  ex- 
tremities and  died  in  collapse.  On  post-mortem  examination  a  large  amount 
of  clotted  blood  was  found  in  the  abdomen.  The  source  of  the  hemorrhage 
was  a  torn  vessel  of  the  mesocolon.  The  uterus  contained  a  fetus  nearly  at 
term  and  dead. 

As  regards  the  diagnosis  of  this  condition,  it  must  be  based  upon  symp- 
toms of  prostration  and  shock  greatly  out  of  proportion  to  the  amount  of 
hemorrhage  that  may  be  present.  The  dangerous  character  of  this  complica- 
tion of  pregnancy  and  labor  should  lead  the  physician  to  take  alarm  promptly 
and  to  interfere  as  quickly  as  possible.  The  method  of  interference  will 
depend  somewhat  upon  whether  the  hemorrhage  occurs  during  labor  or  before 
the  beginning  of  actual  labor.  One  of  the  most  plainly  indicated  expedients 
in  these  cases  is  rupture  of  the  membranes,  which  will  lead  to  a  closer  coap- 
tation of  the  uterus  upon  the  fetal  body,  thus  making  pressure  upon  its 
blood-vessels.  Accompanying  this  rupture  the  administration  of  ergot  or 
ergotin  is  indicated  for  similar  reasons.  Treatment  by  these  expedients  may 
be  considered  the  expectant  method,  which,  in  sixty-three  cases  reported  by 
Storer,  gave  a  mortality  of  forty.  Rapid  dilatation  of  the  os  and  cervix  and 
delivery  by  version  or  by  the  forceps  give  a  better  prognosis,  as  in  eighteen 
forceps  deliveries  four  deaths  are  reported.  "Where,  however,  the  hemor- 
rhage is  sudden  and  severe,  and  the  birth-caual  is  not  sufficiently  dilated  to 
permit  delivery,  the  uterus  should  be  emptied,  and  the  bleeding  be  controlled 
by  abdominal  incision  and  hysterectomy  or  by  total  extirpation  of  the  uterus. 
The  use  of  the  tampon  of  antiseptic  gauze  is  indicated  in  cases  in  which 
hemorrhage  externally  is  considerable  and  the  os  and  cervix  are  too  tightly 
closed  to  permit  of  rapid  delivery.  In  introducing  the  tampon,  it  is  well  to 
pack  the  end  of  the  strip  of,gauze  into  the  os  and  cervix,  thus  furthering 
dilatation  and  checking  external  hemorrhage.  The  prognosis  for  the  fetus 
in  these  cases  is  exceedingly  grave,  and  is  almost  necessarilv  hopeless.  Loss 
of  blood  induces  rapid  asphyxia,  and  the  rapid  fetal  movements  accompany- 
ing the  partly  asphyxiated  state  may  explain  some  of  the  obstinate  uterine 
pains  from  which  these  patients  suffer. 

The  causal  relation  existing  between  involvement  of  the  kidneys  and 
intra-uterine  hemorrhage  has  been  described  in  treating  of  Nephritis  and  its 
consecpiences.  In  a  series  of  clinical  lectures  upon  the  subject  of  hemor- 
rhage during  pregnancy,  Budin1S7  describes  the  case  of  a  patient  suffering 
from  hematuria  with  albuminous  urine.  Profuse  intra-uterine  hemorrhage 
complicated  labor  ;  the  child  perished. 

Larkin183  reports  two  cases  of  concealed  accidental  hemorrhage  in  which 
there  was  no  hemorrhage  from  the  vagina,  and  in  which  the  amniotic  fluid 
was  so  scanty  that  very  little  effect  would  have  resulted  from  rupture  of  the 
membranes. 

The  first  patient,  a  strong,  healthy  woman,  seven  and  a  half*  months  preg- 
nant with  her  seventh  child,  was  taken  suddenly  faint  and  became  uncon- 


THE  PATHOLOGY   OF  PREGNANCY.  227 

scious  while  sitting  in  a  chair.  When  seen,  she  had  a  weak,  quick  pulse, 
was  collapsed  but  conscious.  There  was  continuous  uterine  pain,  very  severe, 
sensation  of  pressure  over  the  pubes,  and  a  desire  to  micturate.  The  uterus 
was  hard  and  tender,  and  there  was  no  hemorrhage  from  the  vagina.  The 
membranes  were  in  close  contact  with  the  fetal  head.  The  patient  was  given 
quinin,  ergot,  and  fluid  nourishment.  The  head  descended  slowly  into  the 
cervix  ;  the  membrane  was  ruptured,  the  patient  having  excessive  pain.  An 
effort  was  made  to  use  de  Ribes'  bag,  but  the  bag  burst.  Version  failed, 
because  the  fetus  was  tightly  surrounded  by  clots.  The  forceps  was  applied 
and  the  child  delivered  stillborn.  The  placenta  was  expelled  with  ease,  and 
a  large  mass  of  clotted  blood  followed  it.  The  patient  made  a  slow  recovery 
under  free  stimulation. 

Larkin's  second  case  was  a  multipara  at  full  term,  who  was  taken  sud- 
denly faint.  She  had  continuous  pain  in  the  uterus  with  exacerbations,  and 
the  womb  was  enlarging.  There  was  no  vaginal  hemorrhage,  and  the  mem- 
branes had  not  ruptured.  The  patient  was  excessively  weak,  and  rallied 
slightly  under  free  stimulation.  The  membranes  ruptured,  and  the  os  was 
dilated  by  the  fingers  and  the  forceps  applied,  with  the  birth  of  a  dead  child. 
The  placenta  and  a  large  mass  of  clots  followed  the  child.  The  patient  had 
no  hemorrhage  after  delivery,  but  died  in  convulsions  several  hours  after  the 
birth  of  the  child. 

Sprigg1-9  reports  the  case  of  a  primipara  a  few  months  pregnant,  who  was 
taken  with  intestinal  obstruction  after  a  pei'iod  of  prolonged  mental  and 
physical  fatigue.  The  urine  became  suppressed  and  the  patient  had  toxemic 
convulsions.  She  was  found  to  have  impacted  feces  in  the  bowels ;  these 
were  removed  by  mechanical  means.  She  improved  so  far  as  excretion 
was  concerned,  but  had  the  usual  symptoms  of  accidental  hemorrhage,  and 
finally  gave  birth  to  a  stillborn  child  at  five  and  a  half  months.  The  placenta 
showed  evidences  of  separation  and  hemorrhage  before  the  birth  of  the  child. 
Coe190  reports  a  fatal  case  of  accidental  hemorrhage.  The  patient  was  a 
primipara,  aged  twenty,  who  during  a  tedious  first  stage  of  labor  had 
a  slight  hemorrhage.  On  examination  the  uterine  tumor  was  larger  and 
softer  than  it  had  been  a  short  time  previously.  The  fetus  could  not  be 
clearly  mapped  out,  and  the  fetal  heart-sounds  could  not  be  heard.  While 
the  patient  was  using  a  commode  she  had  a  profuse  hemorrhage.  The  mem- 
branes were  found  ruptured,  and  the  patient  stimulated.  A  large  dead  child 
was  delivered  by  forceps,  followed  by  the  detached  placenta,  several  large 
clots,  and  over  a  pint  of  fluid  blood.  The  uterus  could  not  be  made  to  con- 
tract after  delivery,  and  the  patient  died  of  shock  about  an  hour  after  the 
birth  of  the  child.  The  placenta  was  the  seat  of  a  general  fatty  and  calcar- 
eous degeneration. 

Marx191  reports  a  case  very  similar  to  that  of  Coe,  in  which  a  fatal  result 
followed.  Both  cases  were  l'emarkable  from  the  fact  that  the  patients  were 
primiparre  in  apparently  good  condition,  that  the  hemorrhage  came  on  sud- 
denly, and  that  the  patient  could  not  be  stimulated  successfully  after  delivery. 


228  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

In  Marx's    case   septic    infection  developed  in   addition  to  the  shock  from 
hemorrhage. 

The  Posture  and  Bearing-  of  the  Pregnant  Woman. — Accompanying 
the  changes  in  the  pelvis  peculiar  to  pregnancy  we  find  certain  variations  in 
the  posture  and  bearing  of  the  patient  as  pregnancy  advances.  This  has 
been  the  subject  of  study  by  Kuhnow,192  who  found  two  types  among  patients 
in  the  later  months  of  pregnancy.  The  most  frecment  is  a  backward  curve 
of  the  entire  body,  while  in  20  per  cent,  of  cases  a  backward  bend  of  the 
trunk  only  was  present.  The  cervical  vertebrae  are  straighter,  the  thoracic 
curve  is  greater  and  more  projecting,  the  lumbodorsal  region  is  straighter, 
its  curve  being  lower  and  flatter,  while  the  pelvic  curve  is  often  lessened  in 
the  later  months  of  pregnancy  and  is  sometimes  unchanged.  The  hip-joints 
are  usually  carried  posteriorly,  while  the  sternum  projects  at  its  lower 
extremity,  increasing  the  diameter  of  the  thorax. 

Relaxation  of  the  Pelvic  Ligaments. — Among  the  general  changes 
caused  by  pregnancy  are  those  affecting  the  joints  of  the  pelvis.  The  fact 
that  an  increased  secretion  of  synovial  fluid  is  present  in  the  pelvic  articula- 
tion during  pregnancy  has  long  been  recognized,  and  has  been  accurately 
studied  by  Driver:195  in  his  examination  of  300  cases  he  found  that  the 
amount  of  relaxation  is  proportionate  to  the  general  strength  and  firmness  of 
the  patient's  tissues.  Age  has  nothing  to  do  with  it,  nor  does  the  amount  of 
relaxation  influence  the  patient's  walking.  Some  of  those  whose  joints  were 
most  relaxed  could  walk  without  difficulty ;  conversely,  considerable  motion 
produced  in  some  patients  marked  lameness.  Pain  at  a  sacro-iliac  joint 
showed  that  the  ilium  moved  upon  the  sacrum  upon  that  side.  This  phe- 
nomenon is  sometimes  observed  in  patients  who  are  not  pregnant.  Some 
patients  recovered  spontaneously  from  a  serious  condition  of  lameness,  while 
others  were  not  benefited  by  prolonged  and  thorough  treatment.  A  slight 
degree  of  relaxation  may  facilitate  delivery  and  obviate  the  use  of  forceps. 
The  most  successful  treatment  described  was  an  abdominal  bandage  of  twilled 
cotton  five  inches  wide,  with  padded  perineal  bands  one  inch  wide.  Where 
the  patient  was  deficient  iu  general  strength  cold  baths  and  massage  were 
sometimes  useful. 

^  The  Toxemia  of  Pregnancy. — The  interesting  metabolism  characteristic 
of  pregnancy  has  not  yet  been  sufficiently  elucidated  to  explain  clearly  the 
origin  of  toxic  material  that  not  infrequently  jeopardizes  the  life  of  mother 
and  of  child.  The  fact  that  nutrition  and  its  converse  are  going  on  in  two 
organisms,  each  dependent  upon  the  other  for  proper  assimilation  and  excre- 
tion, explains  the  ease  with  which  these  processes  may  pass  the  bounds  of 
physiological  activity  and  become  disease.  The  character  of  the  poisons  pro- 
duced in  the  body  of  the  mother  and  the  fetus  places  them,  so  far  as  we  know, 
in  the  class  of  animal  poisons,  alkaloidal  in  nature,  denominated  toxins.  The 
symptoms  they  produce  upon  the  pregnant  patient  are  especially  addressed 
to  the  nervous  system,  hence  the  study  of  toxemia  in  pregnancy  appro- 
priately leads  to  a  consideration  of  nervous  disorders  during  this  condition. 


THE  PATHOLOGY   OF  PREGNANCY.  229 

Various  observers  have,  by  different  methods  of  investigation,  isolated 
several  poisonous  principles  from  the  urine  of  pregnant  women  in  whom 
elimination  was  deficient.  Diihrssen  m  lays  stress  on  the  retention  of  crea- 
tin  and  creatinin  in  the  kidneys  of  the  pregnant  patient.  He  rarely  ob- 
served actual  nephritis,  but  congestion  and  accumulation  of  urine  through 
pressure  upon  the  ureters  and  by  hydronephrosis  he  found  to  be  common. 
Creatin  and  creatinin  accumulating  in  the  vessels  of  the  cerebral  cortex  pro- 
duce cerebral  irritation.  It  is  natural  that  such  a  condition  should  be  com- 
monest in  patients  in  whom  excretion  is  habitually  deficient.  Poisons  ab- 
sorbed from  the  intestinal  tract  stand  in  close  relation  to  the  toxemia  of 
pregnancy,  as  shown  by  Budin.193  This  is  especially  true  where  retrover- 
sion of  the  pregnant  uterus  produces  intestinal  stasis.  In  many  of  these 
cases  the  Bacterium  coli  commune  penetrates  the  wall  of  the  bowel,  causing 
peritonitis  in  adjacent  tissues. 

Culture  experiments  by  inoculation  demonstrating  the  toxicity  of  urine  in 
pregnancy  have  been  performed  by  Charpentier,196  who,  following  Bouchard's 
researches,  injected  such  urine  into  rabbits,  producing  tetanic  convulsions 
and  speedy  death.  Acute  congestion  in  the  kidneys  of  these  animals  was  the 
only  lesion  to  which  the  fatal  issue  could  be  attributed.  Similar  injections 
beneath  the  skin  of  other  animals  less  susceptible  than  rabbits  produced 
death  after  longer  intervals.  The  condition  of  congestion  of  the  kidneys  in 
patients  suffering  from  toxemia  in  pregnane)'  is  also  described  by  Prutz.197 
He  notes  a  very  interesting  point  :  that  but  slight  structural  alterations  were 
present  in  many  exceedingly  severe  cases  of  toxemia.  In  the  kidneys  of 
infants  born  from  mothers  suffering  from  toxemia  there  were  observed 
congestion  and  transudation  of  serum,  with  the  formation  of  casts  in  the 
tubes  and  great  distention  of  the  veins.  A  similar  congestion  in  the  liver 
of  toxemic  patients  is  described  by  Pilliet  and  Delansorme.198  This  con- 
dition of  congestion  in  the  kidney  of  the  pregnant  woman  was  found  in  two- 
thirds  of  the  cases  examined  by  Fischer  during  the  second  half  of  preg- 
nane}7.199 

The  state  of  the  blood  in  these  patients  has  been  studied  by  Blanc,200  who 
made  cultures  and  inoculated  animals  with  their  products,  producing  albu- 
minuria, suppression  of  urine,  and  convulsions.  Intense  congestion  of  the 
kidneys  was  observed  also.  Additional  testimony  as  to  the  extensive  disor- 
ganization of  the  blood  and  the  pathological  condition  of  the  liver  in  the 
toxemia  of  pregnancy  is  afforded  by  Papillon  and  Audain.201  The  accumula- 
tion of  ptomains  in  sufficient  numbers  to  produce  poisoning  has  been  ob- 
served by  Koffer  and  Kundrat.202  Paultauf  and  Kundrat  have  also  reported 
similar  cases  in  the  Records  of  the  Pathological  Institute  of  the  Vienna  Uni- 
versity. 

Among  many  interesting  contributions  to  the  bacteriology  of  this  question 
is  that  made  by  Gerdes.2"3  In  common  with  other  observers  he  is  inclined 
to  ascribe  to  bacteria  a  causal  relation  in  these  cases.  As  bearing  upon  this 
point  we  note  the  observations  of  Tarnier  and  Chambrelent,204  who   found 


230  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

in  toxemic  pregnant  women  that  the  degree  of  intoxication  present  could 
well  be  estimated  by  observing  the  toxicity  of  the  blood-serum  of  these 
patients.  It  is  interesting  to  note,  in  this  connection,  that  any  disorder 
caused  by  bacterial  invasion  predisposes  to  toxemia  in  pregnancy ;  thus 
Lang205  finds  that  twice  as  many  syphilitic  women  show  symptoms  of  threat- 
ened toxemia  in  pregnancy  as  are  observed  in  nonsyphilitic  pregnant  patients. 

The  precise  toxic  agent  responsible  for  the  gradual  development  of  tox- 
emia with  threatened  eclampsia  has  not  yet  been  isolated,  although  a  number 
of  substances  have  been  charged  with  this  result.  The  significance  of  a 
diminished  quantity  of  urea  in  these  cases  has  been  brought  to  the  atten- 
tion of  the  jnrofession  by  Hermann :M  and  Davis.20'  The  latter  in  84  cases, 
with  a  total  of  564  examinations  to  determine  the  quantity  of  urea  present 
in  the  urine  of  pregnant  and  parturient  women,  found  that  the  average 
percentage  of  urea  in  the  urine  of  a  healthy  patient  before  labor  was  1 .4 
per  cent.  After  delivery  this  percentage  increased  to  1.9.  Considerable 
diminution  in  this  quantity  was  first  accompanied  by  symptoms  of  irritation 
of  the  nervous  system  and  threatened  intoxication,  and  when  the  patient's 
excretion  was  not  stimulated  and  the  quantity  of  urea  was  not  brought  up 
nearly  to  normal,  eclampsia  developed.  Davis  does  not  ascribe  the  causal 
role  in  toxemia  to  retained  urea,  but  he  regards  it  as  a  valuable  index  in  esti- 
mating the  excretory  activity  of  the  patient. 

A  well-marked  example  of  ptomain  intoxication  during  pregnancy  is  the 
case  described  by  Gustav  Braun.29S  The  patient,  seven  months  pregnant, 
died  from  pulmonary  edema  after  premature  labor.  The  urine  contained 
casts  and  albumin.  The  postmortem  examination  was  made  by  Paultauf, 
who  found  fatty  liver,  fluid  blood,  nephritis,  and  cerebral  edema.'  Multiple 
rupture  of  capillaries  was  found  in  the  viscera.  The  fact  that  the  blood  of 
patients  suffering  from  toxemia  may  contain  pathogenic  germs  has  been  illus- 
trated by  Blanc,209  who  made  cultures  from  the  blood  of  such  a  patient,  ob- 
taining germs  in  forty-eight  hours  that  caused  albuminuria  and  toxemia  in 
rabbits.  It  was  found,  on  experimenting,  that  chloral,  in  the  proportion  of 
4  :  1000  of  the  culture-liquids,  effectually  destroys  these  germs.  Blanc210 
continued  his  experiments  by  injecting  the  urine  of  pregnant  patients  into 
the  bodies  of  rabbits  and  observing  the  result.  It  was  found  that  although 
the  urine  of  some  nonpregnant  patients  was  poisonous  when  injected,  the 
urine  of  pregnant  patients  was  far  more  toxic,  giving  rise  to  distinct 
phenomena  of  poisoning.  Van  Santvoord,211  from  clinical  observation, 
ascribes  toxemia  during  pregnancy  very  largely  to  deficient  action  of  the 
liver,  by  which  an  insufficient  formation  of  urea  causes  the  patient  to  retain 
toxic  material  in  the  blood.  The  immunity  that  the  kidneys  display  in  some 
of  these  cases  is  illustrated  by  Prutz's  description  of  the  condition  of  the 
kidneys  in  22  cases  of  fatal  toxemia.  In  many  of  these,  beyond  a  general 
congestion,  no  pathological  condition  was  found.  Micro-organisms  were  not 
present  in  the  kidneys,  and  there  was  no  relation  between  the  severity  of 
the  intoxication  and  the  condition  of  the  kidneys.     The  belief  that  peptones 


THE  PATHOLOGY  OF  PREGNANCY.  231 

are  among  the  substances  causing  toxemia  has  led  observers  to  study  the 
urine  of  pregnant  patients  with  regard  to  the  presence  or  absence  of  these 
substances.  Thomson 212  examined  the  urine  of  23  pregnant  and  puerperal 
women  for  peptone ;  the  results  of  his  examination  were  negative.  Koett- 
nitz213  made  140  analyses  of  the  urine  of  31  pregnant  patients,  but  could  not 
discover  that  peptone  is  a  significant  ingredient  in  these  cases.  It  is  often 
present  in  the  urine  of  patients  who  suffer  from  any  severe  complication 
during  pregnancy. 

While  the  entire  subject  of  the  toxicity  of  urine  offers  a  vast  field  for 
investigation  and  has  produced  an  extensive  literature,  so  far  as  the  obstetri- 
cian is  concerned  there  is  abundant  proof  that  no  one  substance  is  especially 
dangerous  to  his  pregnant  patient,  but  that  the  gradual  accumulation  of 
nitrogenous  waste,  of  potassium  combinations,  and  of  animal  alkaloids  pro- 
duces a  condition  of  toxemia  the  symptoms  of  which  are  first  observed  in  a 
disordered  state  of  the  nervous  system  demanding  the  attention  of  the  phy- 
sician. Following  the  line  of  Bouchard,  additional  observation  is  required 
for  a  more  precise  determination  of  the  relative  toxicity  of  the  various  sub- 
stances retained  in  the  blood  in  these  cases. 

Gessner214  calls  attention  to  the  mechanical  element  in  the  causation  of 
toxemia  occasioned  by  tension  upon  the  ureters  from  the  altered  position  of 
the  bladder  during  pregnancy.  He  finds  that  the  growth  of  the  pregnant 
uterus  brings  such  pressure  to  bear  upon  the  ureters,  and  even  upon  the  kid- 
neys, as  to  interfere  with  the  action  of  these  organs. 

Among  the  recent  efforts  to  ascertain  the  relation  between  bacteria  and 
toxemia  is  the  investigation  of  Levinowitsch  215  in  the  Obstetric  Clinic  at 
St.  Petersburg.  He  examined  the  blood  of  44  toxemic  patients  who  had 
eclampsia,  and  found  large  cocci  of  round  and  oval  form  and  very  movable. 
They  were  often  seen  as  diplococci.  They  gave  cultures  on  suitable  media, 
and  were  present  during  the  first  eclamptic  convulsion,  gradually  disappear- 
ing through  forms  of  involution  if  the  patient  recovered.  When  injected 
into  guinea-pigs,  the  cultures  produced  acute  anemia  with  hemorrhagic  endo- 
metritis. In  several  cases  the  same  germs  were  found  in  the  blood  of  the 
fetus. 

The  grounds  for  believing  toxemia  to  be  of  an  infectious  nature  are  set 
forth  by  Stroganoff.216  Toxemia  is  a  general  disease  of  the  organism,  charac- 
terized by  fever  and  followed  by  a  certain  degree  of  immunity  against  another 
attack.  The  severity  of  the  disease  varies  at  different  times,  and  its  frequency 
depends  upon  the  overcrowding  of  the  population.  It  is  transmitted  from 
mother  to  child.  The  writer  believes  the  period  of  incubation  to  be  from 
ten  to  twenty  hours. 

Cases  of  hepatic  toxemia  are  not  frequently  described,  although  it  is  more 
common  than  is  usually  believed.  Fothergill  and  Stenhouse 217  report  the 
case  of  a  woman,  aged  thirty-two,  who  before  completing  the  seventh  month 
of  her  first  pregnancy  had  excessive  swelling  of  the  legs  and  body.  The 
urine  contained  a  quantity  of  bile,  the  liver  was  tender,  and  its  dulness  was 


232  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

increased.  Fluid  collected  within  the  abdomen  was  diminished,  and  the 
liver  dulness  became  reduced.  The  stools  were  absolutely  free  from  bile. 
Labor  was  induced  as  a  last  resort,  after  which  the  patient  improved  and 
ultimately  made  a  good  recovery.  In  a  case  reported  by  Savory 21S  the 
patient  became  highly  toxemic.  She  passed  through  eclampsia  safely  and 
made  a  tardy  convalescence.  During  her  recovery  she  had  a  number  of 
copious  discharges  of  a  most  highly  offensive  and  peculiar  odor  from  the 
bowels.     The  fecal  element  in  the  case  was  a  very  pronounced  one. 

Many  writers  have  referred  to  the  fetus  aud  its  metabolism  as  a  cause  of 
toxemia.  Vauderhoeven 219  writes  in  support  of  the  theory  that  waste  from 
the  fetus  produces  toxemia  and  eclampsia  in  the  mother.  He  reviews  the 
literature  of  the  subject  and  calls  attention  to  the  fact  that  among  576  cases 
of  eclampsia  he  found  but  5  in  which  the  toxemic  state  developed  before  the 
fifth  month  and  only  3  occurred  iit  the  fifth  month.  Nineteen  cases  developed 
in  the  sixth  month  and  the  remainder  later.  A7anderhoeven  argues  from  this 
that  the  accumulation  of  fetal  waste  from  the  growing  child  determines  the 
actual  occurrence  of  toxemia  and  eclampsia. 

The  view  expressed  by  the  writer2'20  that  urea  is  a  valuable  clinical  index 
of  the  perfection  of  the  patient's  assimilation  has  been  accepted  by  many  and 
is  most  emphatically  stated  by  Marx.221  He  found  that  urea  is  always 
diminished  in  the  toxemia  of  pregnancy,  whereas  in  many  desperate  cases 
neither  albumin  nor  casts  are  present.  He  believes  that  progressive  diminu- 
tion in  the  excretion  of  urea,  with  or  without  albuminuria,  is  the  sole  indica- 
tion of  value  for  the  induction  of  premature  labor  to  avoid  eclampsia. 

The  toxicity  of  urine  has  been  studied  during  the  past  few  years  by 
Stewart,  who  has  contributed  several  papers  upon  the  subject.222  A  review 
of  his  experiments,  with  the  papers  of  Duhrssen,223  Laulame  and  Chambre- 
lent,224  Ludwig  and  Savor,225,  Volhard,226  Saft,227  Schmorl,223  Massen,229  and 
Kronig,230  points  to  the  fact  that  poisons  of  unknown  nature  are  constantly 
present  in  the  urine  of  pregnant  and  nonpregnant  women  ;  in  proportion  as 
the  metabolism  is  normally  performed  the  ui'ine  is  abundant  in  quantity 
and  rich  in  poisons  that,  if  injected  into  animals,  cause  convulsions  and 
death.  The  blood-serum  of  these  patients  is  not  poisonous.  In  cases,  how- 
ever, in  which  toxemia  develops  there  is  first  a  diminution  in  urea,  showing 
that  normal  metabolism  is  failing,  and  an  accumulation  of  poisons  in  the 
glandular  organs.  The  blood-serum  becomes  highly  poisonous  ;  if  the  urine 
is  greatly  lessened  in  quantity,  it  may  be  more  than  usually  toxic,  whereas  in 
some  instances  its  ratio  of  toxicity  is  not  increased  or  maybe  diminished.  It 
seems  rational  to  conclude  that  a  normal  percentage  of  urea  is  not  incompat- 
ible with  a  urine  toxic  to  animals,  but  that  a  lessened  excretion  of  urea  with 
diminished  quantity  of  urine  and  often  with  lessened  toxicity  means  an 
accumulation  of  poisons  in  the  blood,  and  this  indicates  toxemia  and  should 
warn  against  eclampsia. 

The  lesions  produced  by  advanced  toxemia  and  eclampsia  are  those  caused 
by  the  circulation  of  highly  toxic  blood-serum  in  those  parts  of  the  body 


THE  PATHOLOGY   OF  PREGNANCY.  233 

most  rich  in  blood  supply.  Thus,  in  the  liver  are  found  the  punctate  hem- 
orrhages and  areas  of  cellular  necrosis  seen  in  hepatic  toxemia.  In  the 
mucous  membrane  of  the  intestine  and  stomach  are  found  evidences  of  the 
dissolution  of  the  blood  and  the  breaking  down  of  the  walls  of  the  blood- 
vessels. In  the  lungs,  in  patients  who  survive  eclampsia  but  die  from 
exhaustion,  is  seen  a  gangrenous  pneumonia  with  multiple  extravasations  of 
blood.  In  the  mucous  membranes  of  various  portions  of  the  body  are 
observed  the  smaller  hemorrhages  and  lesions  characteristic  of  the  condition. 
If  the  case  be  an  acute  and  recent  one,  the  lesions  in  the  kidney  resemble 
those  in  other  organs.  If  the  process  has  developed  gradually,  the  kidney 
epithelia  show  degenerative  rather  than  acute  change. 

The  altered  pulse  tension  in  toxemia  has  long  been  recognized  as  a  valu- 
able diagnostic  sign.  The  tension  is  evidently  increased,  the  pulse  being 
hard,  tense,  and  resistant  to  the  finger.  This  phenomenon  increases  in 
intensity  until  the  outbreak  of  the  eclamptic  convulsion.  It  is  one  of  the 
most  valuable  diagnostic  symptoms  of  the  condition. 

Tridondani a"  publishes  an  interesting  paper  with  sphygmographic  tracings 
clearly  portraying  the  character  of  the  pulse  in  toxemia  and  threatened 
eclampsia.  These  tracings  emphasize  the  strong  systolic  impulse,  the  rapid 
fall  of  pressure,  and  the  rebound.  As  the  convulsion  begins  the  line  of 
ascent  is  longer  and  its  summit  sharper,  whereas  between  convulsions  the 
line  of  ascent  is  much  shorter  and  lacks  the  sharp  rebound  seen  in  the  former 
condition. 

The  changes  that  toxemia  produces  in  the  fetus  have  been  described 
repeatedly.  It  is  rare  to  find  a  case  in  which  an  early  ovum  has  shown 
signs  of  toxemia.  Griffith  and  Eden  aB  report  the  case  of  a  patient  who  had 
eclampsia  at  the  eighth  month  of  her  third  pregnane}'.  She  recovered  after 
the  induction  of  labor.  Eighteen  months  afterward  she  became  pregnant, 
and  severe  symptoms  appeared  as  early  as  the  fifth  week.  The  uterus  was 
dilated  by  the  rapid  method,  and  the  ovum  was  removed.  The  symptoms 
disappeared  speedily,  but  a  trace  of  albumin  persisted  in  the  urine  for  some 
time.  The  ovum  was  apparently  healthy,  but  upon  microscopical  examina- 
tion showed  myxomatous  and  fatty  degeneration  first  in  the  decidua,  and 
later  in  the  chorion.  The  cells  in  the  chorion  showed  vacuolation  like  that 
of  the  decidua,  with  deposit  of  fat  in  the  villi. 

Alfieri m  contributes  an  interesting  paper  upon  the  fetal  lesions  in 
eclampsia.  The  lesions  correspond  in  the  main  with  those  found  in  the 
body  of  the  mother,  and  point  distinctly  to  auto-intoxication.  It  was 
impossible  to  attribute  the  fetal  death  to  any  lesion  found  in  the  kidneys  or 
suprarenal  capsules,  as  the  general  picture  of  auto-intoxication  remained  a 
very  complete  and  perfect  one. 

The  prophylaxis  of  toxemia  resolves  itself  into  the  maintenance  of  excre- 
tion. Remembering  the  interference  with  the  circulation  to  which  the 
patient  is  subjected  by  pressure,  a  first  and  very  important  precaution  is  to 
secure  suitable  clothing.     There  can  be  no  question  of  the  advisability  of 


234  AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 

laying  aside  completely  the  corset  and  any  other  form  of  support  for  skirts 
that  compresses  the  abdomen  and  forces  the  viscera  down  upon  the  brim  of 
the  pelvis.  The  art  of  dress  has  advanced  sufficiently  to  enable  the  patient 
to  obtain  comfortable  and  shapely  clothing  supported  entirely  from  the 
shoulders.  Poor  patients  can  construct  from  cheap  materials  waists  that 
fulfil  the  same  indication.  The  intelligent  physician  will  advise  and  urge 
strongly  that  the  corset  be  laid  aside,  but  he  will  remember  that  this  is  one 
of  the  pieces  of  medical  advice  that  is  expected  and  rarely  followed.  The 
responsibility,  however,  is  not  his  after  he  has  stated  the  case  fairly  and 
clearly  to  his  patient.  Constriction  of  the  blood-vessels  should  also  be 
avoided  by  wearing  loose  shoes,  by  dispensing  with  garters  that  encircle  the 
legs,  and  by  the  avoidance,  so  far  as  possible,  of  constipation.  For  the 
latter  difficult  problem,  it  will  be  found  that  a  proper  mode  of  dress,  by  over- 
coming pressure  upon  the  large  intestine,  is  of  the  utmost  importance.  In 
addition  it  is  well,  also,  for  the  patient  to  select  a  diet  that  is  not  rich  in 
nitrogenous  elements.  The  heavier  and  less  digestible  meats  should  be 
omitted.  Poultry  and  game,  lamb,  mutton,  fish,  and  oysters  are  best  adapted 
for  such  patients.  An  abundance  of  raw  fruit,  or  stewed  fruit  if  the  diges- 
tion is  defective,  is  of  great  importance.  Whole  wheat,  Graham,  and  rye 
breads  are  of  value.  Sweets  and  stimulants  of  every  form  are  also  counter- 
indicated.  Vegetables  are  useful,  but  are  inferior  to  fruits  for  the  needs  of 
such  patients.  The  driuking  of  water  in  abundance  is  a  prime  necessity. 
If  the  patient  cannot  obtain  bottled  waters,  ordinary  drinking-water  that  has 
been  boiled  and  filtered  may  be  taken.  If  the  patient's  means  allow,  she 
will  find  the  lightest  ATichy  or  any  of  the  slightly  alkaline  and  effervescing 
waters  agreeable  and  advantageous.  Milk  is  to  be  taken  freely  by  those 
with  whom  it  agrees ;  in  many,  however,  its  use  produces  obstinate  constipa- 
tion. Milk  can  often  be  taken  diluted  with  A^ichy  or  Apollinaris  or  soda- 
water.  Its  constipating  properties  may  be  overcome  by  taking  oatmeal 
crackers  or  gruels  of  various  sorts  with  the  milk.  If  it  causes  indigestion, 
it  may  be  peptonized  or  pancreatized.  It  may  be  made  into  junket  or  milk- 
puddings.     Buttermilk  is  relished  by  some  patients. 

The  medicinal  treatment  of  intestinal  torpor  threatening  toxemia  con- 
sists in  the  use  of  such  laxatives  as  may  be  employed  for  a  considerable 
time  without  violent  purgation  and  without  losing  their  effect.  Compound 
licorice  powder  in  small  quantities,  rhubarb  or  colocynth  in  combination  with 
extract  of  belladonna,  small  quantities  of  the  heavier  mineral  waters,  such 
as  Hunyadi  Janos,  and  cascara  sagrada  in  combination  with  the  substances 
mentioned,  have  been  found  efficient.  When  the  liver  evidently  is  at  fault, 
the  occasional  use  of  calomel  and  soda,  followed  by  a  saline,  is  distinctly 
indicated.  When  hemorrhoids  complicate  constipation,  rectal  suppositories 
of  glycerin,  1  dram,  extract  of  belladonna,  i  grain,  and  iodoform  5  grains, 
\vill  be  found  advantageous. 

In  addition  to  avoiding  constipation,  the  prophylaxis  of  toxemia  embraces 
such  care  of  the  skin  as  shall  promote  constant  and  free  elimination.     Fre- 


THE  PATHOLOGY   OF  PREGNANCY.  235 

quent  bathing  in  tepid  water,  flannel — varying  in  weight  in  accordance  with 
the  climate — worn  next  the  skin,  massage  of  the  limbs  and  the  upper  por- 
tion of  the  trunk,  and  gentle  exercise  are  not  to  be  neglected.  In  view  of 
the  important  part  that  the  lungs  play  in  excretion  and  the  necessity  for  a 
free  supply  of  oxygen,  the  patient  must  have  an  abundance  of  fresh  air.  A 
mild  and  equable  climate  is  naturally  the  best  for  such  cases,  but  as  this  is 
seldom  available,  the  patient,  properly  clad,  should  be  out-of-doors  in  all 
weathers.  The  quantity  of  urine  secreted  must  be  observed,  and  the  patient 
should  be  instructed  to  take  such  precautions  as  will  render  this  information 
available  for  the  physician.  He  may  inform  her  that  a  quantity  varying 
within  certain  limits  is  what  is  expected  and  desired,  and  that  any  marked 
decrease  from  this  should  at  once  be  reported  to  him.  The  examination  of 
the  urine  of  pregnant  patients  should  not  be  omitted  in  any  case,  and  it 
should  be  done  at  least  once  a  month  through  the  entire  pregnancy  or,  better, 
once  in  two  or  three  weeks.  Although  this  imposes  additional  labor  upon 
the  physician  and  inconvenience  upon  the  patient,  yet  in  all  cases  of  primi- 
gravidse,  especially  in  women  whose  nutrition  and  excretion  are  not  of  the 
best,  "  Eternal  vigilance  is  the  price  of  safety."  If  this  be  reasonably 
explained  to  a  patient,  she  will  rarely  object.  The  examination  of  the  urine 
in  pregnancy  should  be  made  by  chemical  and  microscopical  methods.  By 
the  chemical  method  we  search  for  albumin,  sugar,  and  urea  in  all  cases. 
By  the  microscopical  study  of  the  specimen  we  derive  positive  and  valuable 
information  as  to  the  condition  of  the  parenchyma  of  the  kidney,  and  this 
information  can  be  obtained  in  no  other  way.  Hence  in  pregnancy  an 
examination  of  the  urine  that  does  not  include  its  microscopical  study  is 
certainly  superficial  and  deficient.  In  cases  in  which  a  suspicion  exists  that 
toxemia  is  developing,  in  addition  to  the  substances  already  mentioned,  we 
must  examine  chemically  for  indican,  acetone,  peptone,  pus,  and  blood.  In 
complicated  cases  microscopical  examination  must  be  prolonged  and  thorough. 

In  diagnosticating  the  toxemia  of  pregnancy  two  clinical  signs  are  of 
especial  value  :  first  in  importance  are  the  amount  and  character  of  the 
excretions  ;  second,  is  the  condition  of  the  nervous  system.  The  first  sign 
is  to  be  ascertained  by  careful  questioning  and  accurate  observation.  The 
second  sign  must  be  determined  by  closely  interrogating  the  various  functions 
of  the  patient's  nervous  system.  The  presence  or  absence  of  paiu,  head- 
ache, thirst,  lassitude,  disturbances  of  vision,  of  hearing,  or  of  taste,  sleep- 
lessness or  lethargy,  irritability  or  apathy,  melancholia,  and  nausea  and 
vomiting,  are  all  symptoms  to  be  recognized  or  eliminated.  The  condition 
of  the  skin  is  of  great  value,  as  affording  evidence  of  the  functional 
integrity  of  its  excretory  apparatus.  Of  secondary  importance  are  the 
occurrence  of  swelling  of  the  feet  and  legs  and  the  presence  of  serum- 
albumin  only  in  the  urine. 

The  treatment  of  the  toxemia  of  pregnancy  consists  in  the  prompt  stimula- 
tion of  all  the  eliminative  organs  of  the  body.  In  view  of  the  hepatic  con- 
dition present  there  can  be  no  question  regarding  the  efficiency  of  mercurials 


236  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

in  repeated  doses.  The  remarkable  effect  of  calomel  is  especially  of  value 
in  these  cases.  In  selecting  saline  cathartics  it  is  best  to  avoid  those 
containing  potassium  salts,  as  potassium  has  been  shown  to  be  an  irritative 
element  in  the  urine.  Those  purgatives  producing  a  free  flow  of  watery 
fluid  from  the  bowel,  such  as  colocynth,  elaterium,  and  jalap,  are  especially 
indicated.  Rectal  injections  of  glycerin,  combined  with  sodium  salts  and 
spirits  of  turpentine,  are  excellent  in  producing  copious  watery  evacuations. 
The  beneficial  effect  of  such  eliminative  treatment  on  the  nervous  system  is 
remarkable  in  many  cases,  the  patient  passing  from  a  condition  of  melan- 
cholia and  great  restlessness  to  a  feeling  of  comfort  and  good  health.  Warm 
and  hot  baths  in  these  cases,  taken  before  retiring,  are  an  excellent  means  of 
treatment.  If  the  patient's  symptoms  are  threatening  and  a  condition  of 
hysteria  is  present,  the  hot  pack  will  prove  a  most  valuable  resource.  The 
diet  in  cases  of  toxemia  should  be  restricted  to  milk,  fruit,  bread,  and,  if 
more  than  this  is  necessary,  fish,  oysters,  and  gruel.  Meats,  eggs,  vegetables, 
pastry,  and  all  forms  of  stimulants,  including  tea  and  coffee,  should  be  for- 
bidden absolutely  while  symptoms  of  toxemia  are  present.  In  examining  the 
urine  two  points  are  especially  valuable  :  the  first  is  the  quantity  passed  daily ; 
the  second,  the  quantity  of  urea  excreted  by  the  patient.  If  the  condition 
of  the  kidney  passes  beyond  congestion  to  actual  nephritis,  the  practitioner 
will  be  aware  of  this  through  the  microscopical  study  of  the  urine,  when 
bloody,  epithelial,  or  fatty  casts  will  be  present.  The  presence  of  serum- 
albumin  and  hyaline  casts  is  of  very  little  moment  so  long  as  a  free  amount 
of  urea  is  excreted,  and  microscopical  study  of  the  urine  finds  no  evidence 
that  the  parenchyma  of  the  kidney  is  diseased. 

It  is  evident  from  what  has  been  stated  regarding  the  toxemia  of  preg- 
nancy that  simple  albuminuria  is  of  but  slight  importance  in  the  pregnant  con- 
dition. The  complications  of  pregnancy  ascribed  to  albuminuria  do  not  result 
from  the  presence  of  serum-albumin  in  the  urine,  but  from  the  circulation, 
through  the  body' of  the  mother  and  her  placenta,  of  blood  rendered  irritating 
by  toxic  material.  The  occurrence  of  thickening  and  induration  in  the  walls 
of  the  placental  blood-vessels,  the  partial  separation  of  a  placenta  in  fatty 
degeneration  following  this  process,  with  the  consequent  hemorrhage  and 
asphyxia  of  the  fetus,  are  familiar  complications  of  the  toxemia  of  preg- 
nancy, and  they  follow  the  diffusion  of  toxic  material  in  the  placental  blood. 
Simple  albuminuria  is  often  seen  in  multigravkke  in  whom,  by  reason  of 
the  large  size  of  the  fetus  or  by  the  relaxed  condition  of  the  uterus  and  the 
abdominal  walls,  the  ureters  are  pressed  upon  and  the  kidneys  are  in  a  con-, 
stant  state  of  congestion  and  accumulation  of  urine.  Many  of  the  women 
thus  affected  exhibit  edema  of  the  extremities ;  they  remain  entirely  free 
from  those  disturbances  of  the  nervous  system  seen  in  toxemia.  The  condi- 
tion of  such  patients  does  not  demand  the  induction  of  abortion  ;  the  indica- 
tions are  to  stimulate  the  heart-muscle,  to  maintain  the  circulation  in  every 
way,  and,  if  possible,  to  relieve  the  pressure  of  the  pregnant  uterus  upon 
the  ureters  by  a  supporting  bandage,  when  this  can  be  used. 


THE  PATHOLOGY   OF  PREGNANCY.  237 

In  sharp  distinction  to  these  cases  are  those  of  the  toxemia  of  pregnancy, 
in  which,  notwithstanding  prompt  treatment  addressed  to  the  organs  of 
elimination,  the  patient's  nervous  symptoms  continue,  and  her  excretory  proc- 
esses are  plainly  deficient.  In  the  present  state  of  our  knowledge  the 
prompt  termination  of  pregnancy  in  such  cases  is  the  only  rational  and  con- 
servative treatment.  If  the  toxemia  of  pregnancy  is  recognized  and  the 
patient  will  submit  to  her  physician's  advice,  eclampsia  should  become  as 
rare  as  puerperal  septic  infection. 

The  tendency  of  patients  who  suffer  from  toxemia  of  pregnancy  to  pass 
into  nephritis  after  pregnancy  or  during  a  subsequent  gestation  must  be  borne 
in  mind.  In  a  woman  who  has  once  shown  marked  evidence  of  the  toxemia 
of  pregnancy  each  succeeding  gestation  brings  added  risk  of  fatal  poisoning. 
If  her  condition  remains  undetected  and  her  general  health  after  parturition 
is  neglected,  she  will  not  infrecpiently  become  the  victim  of  nephritis. 

Eclampsia. — The  culmination  of  toxemia  is  that  explosion  of  nervous 
energy  called  eclampsia.  The  term  applies  strictly  to  convulsions  of  any 
sort,  and  the  eclampsia  of  infants  has  been  familiar  to  physicians  for  many 
years.  Usage  has  limited  the  word  in  ordinary  application  to  the  convul- 
sions of  pregnant  women  caused  by  toxemia. 

The  many  theories  that  have  been  advanced  to  account  for  eclampsia  do 
not  demand  detailed  consideration.  None  of  them  is  satisfactory,  and 
most  of  them  are  based  upon  a  superficial  and  very  imperfect  consideration 
of  the  pathology  of  the  condition.  Eclampsia  has  been  attributed  to  acute 
cerebral  anemia  because,  in  some  cases,  the  brain  has  been  found  anemic. 
Because  pressure  upon  the  ureters  would  interfere  with  the  circulation  of 
the  kidney  and  with  elimination,  such  pressure  has  been  alleged  to  cause 
eclampsia.  The  only  explanation  that  results  in  a  satisfactory  prophylaxis 
and  treatment  is  that  which  recognizes  the  circulation  of  toxic  blood  through 
the  nervous  centers  and  the  resulting  excitement  of  these  nervous  centers  as 
the  cause  of  eclampsia.  Conditions  of  analogous  irritation  of  the  nervous 
system  are  frecpiently  observed  in  non-pregnant  patients  suffering  from  dis- 
ordered elimination.  It  is  evident  that  the  poison  of  eclampsia  must  differ 
from  that  of  uremia,  as  many  uremic  patients  escape  convulsions. 

The  prodromal  symptoms  of  eclampsia  are  those  of  exaggerated  toxemia. 
Severe  headache,  disturbances  of  vision  with  flashes  of  fire  before  the  eyes 
or  progressive  loss  of  sight,  dulness  of  intellect,  and  increased  reflex  excita- 
bility are  usually  present.  The  pulse  tension  is  much  increased,  and  the 
heart-beat  is  heavy  and  strong.  Various  disturbances  of  intellect  have  been 
noted.  In  one  of  the  writer'  s  cases  the  patient  became  suddenly  maniacal 
and,  without  cause,  attacked  her  sister.  In  another  the  patient  was  admitted 
to  a  hospital,  passed  through  severe  eclampsia,  and  did  not  become  conscious 
of  her  past  for  nearly  a  week  after  her  admission.  She  did  not  remember 
coming  to  the  hospital  and  supposed  herself  still  in  her  own  home.  In  some 
cases  eclampsia  seems  to  develop  without  symptoms,  but  in  these  patients  it 
is  rational  to  believe  that  symptoms  had  escaped  observation.     When  we 


238  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

remember  how  few  pregnant  patients  are  subjected  to  careful  study,  it  can 
readily  be  seen  that  symptoms  that  increase  in  severity  but  slowly  often 
escape  observation. 

The  eclamptic  lit  resembles  exactly  hystero-epilepsy.  From  the  parox- 
ysms alone  an  exact  diagnosis  cannot  be  made.  In  a  case  seen  in  consultation 
by  the  writer  a  pregnant  woman,  during  the.  first  stage  of  labor,  simulated 
eclampsia  so  closely  as  to  deceive  several  physicians  in  attendance.  The  urine 
contained  serum-albumin  in  small  quantity,  but  the  patient's  excretions  were 
well  performed.  It  was  observed  that  she  had  no  fits  when  alone,  and  that 
each  examination  was  the  occasion  of  convulsions.  When  the  patient  was 
left  in  charge  of  a  nurse  alone,  her  convulsions  ceased  and  she  finally  passed 
into  normal  labor.  The  convulsions  of  acute  dementia  may  be  mistaken  for 
eclampsia.  A  case  admitted  to  the  Jefferson  Maternity  was  supposed,  by  the 
attending  physician,  to  be  eclampsia.  Upon  examination  the  urine  was  found 
to  be  normal,  but  the  patient's  mental  condition  was  that  of  a  dement.  Her 
convulsions  were  an  expression  of  her  suffering  in  labor.  After  delivery 
she  was  sent  to  a  hospital  for  the  insane,  where  she  made  a  temporary  recov- 
ery from  her  dementia.  The  differential  diagnosis  between  the  convulsions 
of  eclampsia  and  those  of  hystero-epilepsy,  epilepsy,  insanity,  strychnin- 
poisoning,  and  other  conditions  producing  convulsions  is  to  be  made  by 
examining  the  patient  for  evidences  of  toxemia.  The  urine  can  usually  be 
obtained  for  examination.  The  condition  of  the  digestive  tract  can  be  ascer- 
tained from  an  inspection  of  the  tongue  and  from  the  presence  or  absence  of 
intestinal  engorgement.  The  state  of  the  skin,  of  the  mucous  membranes, 
and  of  the  pulse  will  assist  in  the  diagnosis. 

When  is  eclampsia  especially  liable  to  occur?  Observation  shows  that 
patients  of  gouty,  anemic,  rheumatic,  and  neurotic  tendencies  are  especially 
susceptible  to  eclampsia.  Prkniparse  beyond  the  average  age  of  child-bear- 
ing and  multipara  exhausted  by  frequent  child-bearing,  ill  fed,  and  in  bad 
general  condition,  and  patients  accustomed  to  eat  large  quantities  of  meat 
and  rich  and  indigestible  foods  are  especially  liable  to  eclampsia.  Women 
who  drink  large  quantities  of  tea  and  coffee  and  lead  sedentarv  lives  fre- 
quently have  eclampsia. 

During  pregnancy  there  occurs  in  most  patients,  from  four  to  six  weeks 
before  the  time  of  labor,  a  considerable  diminution  in  the  solid  waste  removed 
from  the  body.  Occasionally  this  diminution  in  excretion  is  greatest  just 
before  the  head  of  the  child  in  primiparse  begins  to  descend  into  the  pelvis. 
This  is  followed  by  an  increase  in  the  solids  excreted  until,  in  healthy 
patients,  the  condition  of  the  urine  just  before  labor  shows  a  considerable 
improvement.  We  have  no  explanation  to  offer  for  this  phenomenon,  but 
have  observed  it  repeatedly.  Eclampsia  has  been  known  to  occur  at  the  . 
seventh  month  of  gestation  and  occasionally  as  early  as  the  sixth.  In  the 
larger  number  of  cases  the  patient  does  not  go  to  full  term  exactly  before 
eclampsia  interrupts  the  pregnancy. 

The  determining  cause  of  eclamptic  convulsions  may  be  toxic  or  median- 


THE  PATHOLOGY  OF  PREGNANCY.  239 

ical,  or  may  act  through  the  medium  of  the  brain.  An  abundant  meal  of 
indigestible  food  may  result  in  eclampsia.  The  induction  of  labor  to  prevent 
eclampsia  may  precipitate  the  convulsions.  A  fright  or  shock  in  a  patient 
highly  toxemic  may  bring  on  eclampsia.  Exposure  to  wet  and  cold  and 
sudden  changes  of  temperature  favor  its  development.  In  some  cases  no 
determining  cause  can  be  recognized  and  eclampsia  apparently  develops 
because  the  nervous  system  can  no  longer  tolerate  the  poisoned  blood  that 
circulates  through  it. 

In  eclamptic  convulsions  the  patient  becomes  unconscious,  turns  the  face 
and  eyes  toward  the  right,  has  tonic  and  clonic  spasms  of  the  entire  muscular 
system,  becomes  partially  asphyxiated,  is  blue  in  the  face,  froths  at  the 
mouth,  and  often  wounds  the  tongue  by  unconsciously  biting  it.  If  uncon- 
trolled, such  paroxysms  return  with  increasing  frequency  and  severity  until 
the  child  is  expelled  from  the  uterus  or  the  mother  dies  of  exhaustion.  The 
convulsions  bring  on  engorgement  of  the  lungs  with  edema,  weaken  the 
heart  through  exhaustion  of  its  muscle  and  dilatation  of  the  right  ventricle, 
exhaust  the  centers  of  the  brain  that  regulate  heat  and  the  vasomotor  system, 
and,  as  the  patient  ceases  to  excrete,  bring  unconsciousness  to  coma,  carbon 
dioxid  poisoning  and  exhaustion  terminating  in  death.  The  pulse-rate 
increases  as  the  heart  becomes  exhausted,  and  the  temperature  rises  as  the 
heat  center  yields  to  the  depressing  influences  that  attack  it.  Should  the 
patient  survive  the  eclamptic  paroxysms  and  be  delivered,  she  may  perish 
from  a  gangrenous  pneumonia,  from  acute  nephritis,  from  degeneration  of 
the  liver  substance,  from  edema  of  the  brain,  from  cerebral  hemorrhage,  from 
dilatation  of  the  heart,  or  from  exhaustion  alone. 

A  patient  may  recover  from  eclampsia  and  go  on  in  pregnancy.  Although 
this  is  unusual,  the  circumstance  draws  attention  to  the  fact  that  eclampsia 
is  a  disease  of  pregnancy  and  not  a  complication  of  labor ;  hence  the  most 
successful  treatment  of  eclampsia  will  be  directed  to  the  cause  of  the  attack 
and  not  immediately  to  the  termination  of  pregnancy. 

Although  eclampsia  is  most  likely  to  occur  in  the  last  eight  weeks  of 
pregnancy,  it  has  been  seen  at  an  earlier  period  of  gestation.  Dewar234 
reported  to  the  Edinburgh  Obstetrical  Society  the  case  of  a  primipara 
six  months  pregnant,  and  previously  a  healthy  woman.  She  had  not  had 
scarlet  fever  and  suffered  during  pregnancy  with  very  little  sickness  and 
slight  swelling  of  the  feet  and  ankles.  She  had  been  constipated,  and  was 
seized  with  convulsions  without  warning.  The  bowels  were  emptied  by 
soap-and-water  enema,  and  the  urine  was  taken  by  catheter  and  examined. 
It  was  found  to  be  free  from  albumin.  She  was  given  potassium  bromid  and 
chloral  hydrate  with  veratrum  viride,  and  the  convulsions  ceased  temporarily. 
They  recurred  again,  and  in  all  she  had  three  series  of  convulsions,  from 
each  of  which  she  gradually  recovered  without  the  occurrence  of  labor. 
Three  months  after  her  first  convulsion  she  was  delivered  in  spontaneous 
labor  and  made  a  good  recovery.  The  child  was  well  developed,  and  the 
only  sequel  that  could  be  detected  was  a  slight  defect  in  the  patient's  memory. 


240  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

This  case  is  of  especial  interest  iu  view  of  the  following  facts  :  the  early 
period  of  pregnancy  in  which  eclampsia  occurred  ;  the  fact  that  the  urine 
was  free  from  albumin,  but  that  fecal  intoxication  was  present ;  the  recovery 
of  the  patient  from  eclampsia ;  the  continuance  of  pregnancy  and  her  spon- 
taneous delivery  with  uninterrupted  recovery.  This  case  emphasizes  the 
importance  that  toxins  derived  from  retained  feces  play  in  the  production  of 
eclampsia. 

Ballantyne235  reports  a  case  of  eclampsia  occurring  as  early  as  the  sixth 
month.  The  patient  was  treated  by  the  hypodermic  use  of  tincture  of  vera- 
trum  viride,  hypodermoclysis  with  saline  solution,  rectal  injections  of  chloral 
bromid,  and  the  induction  of  labor.     She  recovered. 

In  discussing  the  treatment  of  eclampsia  two  views  must  be  kept  in  mind. 
The  first  is  that  which  considers  eclampsia  as  in  a  large  measure  independent 
of  the  presence  of  the  fetus,  and  hence  does  not  urge  immediate  emptying 
of  the  uterus.  The  second  view  is  that  which  holds  that  eclamptic  convul- 
sions generally  cease  after  the  fetus  has  been  delivered,  and  hence  that  the 
uterus  should  be  emptied  as  soon  as  possible.  The  wiser  plan  as  regards 
treatment  takes  cognizance  of  both  views,  and,  neglecting  neither,  meets 
both  indications.  A  symposium  upon  this  subject  gives  the  views  of  a 
number  of  American  obstetricians.236  It  is  generally  agreed  that  three  indi- 
cations are  present :  to  control  the  convulsions  ;  to  secure  elimination  ;  and 
to  secure  the  emptying  of  the  uterus.  That  plan  of  treatment  that  accom- 
plishes these  is  most  successful. 

To  control  convulsions,  the  inhalation  of  chloroform,  of  ether,  of  chloro- 
form and  oxygen,  or  of  other  anesthetic  vapor  has  been  employed,  The 
most  prompt  and  efficient  agent  for  this  purpose  undoubtedly  is  chloroform. 
Recently  some  observers,  noticing  the  carbon  dioxid  poisoning  that  so  rapidly 
develops  during  eclamptic  cpnvulsions,  have  suggested  the  inhalation  of 
oxygen  under  pressure  as  especially  useful,  combined  with  chloroform  or 
even  as  a  substitute  for  it.  Antispasmodic  drugs,  such  as  chloral  hydrate, 
the  bromids,  antipyrin,  antifebrin,  and  opium  have  long  been  used  to  control 
convulsions.  Eclampsia  has  been  treated  exclusively  by  large  doses  of 
opium,  and  cases  have  recovered  under  this  treatment.  To  relax  pulse  ten- 
sion and  inhibit  spasm,  veratrum  viride  has  been  employed  extensively.  It 
may  be  used  hypodermically,  and  is  an  agent  of  great  power  and  rapid  action. 

To  secure  elimination,  prompt  and  vigorous  purging  with  croton  oil, 
calomel,  jalap,  and  salts  is  usually  employed.  The  skin  is  made  to  act  by 
pilocarpin  or  hot  packs  and  baths.  The  kidneys  are  roused  to  action  by  the 
ingestion  of  large  quantities  of  wrater  or  of  normal  salt  solution  introduced 
into  the  stomach,  the  intestine,  beneath  the  skin,  or  into  the  veins.  Calomel 
and  digitalis  are  also  given  for  this  purpose.  In  bleeding,  the  effort  has  been 
made  to  remove  poisoned  blood,  to  lessen  pulse  tension,  and  to  secure  the 
relaxing  effect  that  follows  free  bleeding. 

To  secure  prompt  delivery,  Cesarean  section  has  been  practised,  the  cervix 
has  been  stretched  or  incised  and  the  child  extracted,  labor  has  been  induced 


THE  PATHOLOGY   OF  PREGNANCY.  241 

by  the  introduction  of  bougies,  and  the  child  has  been  sacrificed  by  embry- 
otomy whenever  this  was  considered  necessary.  These  are  the  methods  of 
treatment  that  have  received  the  approval  of  competent  authorities  and  that 
have  given  some  measure  of  success  in  the  treatment  of  this  condition. 

To  aid  the  reader  in  a  selection  of  methods  of  treatment,  we  cite  briefly 
some  of  the  most  interesting  and  instructive  recent  literature  upon  the  sub- 
ject. Although  veratrum  viride  has  long  been  a  domestic  remedy  of 
acknowledged  value  in  the  United  States,  it  has  also  received  the  sanction 
of  experiment  and  use  in  other  countries.  Mangiagalli w  reports  20  cases 
of  eclampsia  treated  with  veratrum  viride.  His  results  were  decidedly 
favorable  and  he  warmly  recommends  this  agent.  A  most  useful  resource 
in  the  treatment  of  eclampsia  is  the  injection  of  saline  fluid.  Jardine238 
employed  one  part  of  potassium  bicarbonate  to  three  of  common  salt, 
making  one  dram  to  the  pint  of  sterilized  water  at  100°  F.  A  simple 
apparatus  that  can  be  sterilized  enables  the  physician  to  apply  this  treatment 
at  any  time.  Injections  may  be  made  beneath  the  edge  of  the  breast  and  in 
the  abdominal  wall  after  delivery.  Jardine  239  reports  another  series  of  22 
cases,  illustrating  the  value  of  this  treatment.  In  a  further  contribution  he 
reported  additional  cases.240  In  still  another  paper241  he  quotes  the  statistics 
of  the  Glasgow  Maternity  Hospital  during  fifteen  years  ;  in  the  use  of 
chloroform,  chloral,  bromid,  veratrum  viride,  or  morphin  the  mortality  was 
47  per  cent. ;  wdien  saline  injections  were  added  to  the  treatment,  the  mor- 
tality fell  to  17  per  cent.  The  cases  were  most  of  them  desperate,  and  had 
been  in  convulsions  some  hours  before  admission. 

The  clinical  fact  that  in  many  cases  of  eclampsia  convulsions  cease  after 
the  uterus  is  emptied,  and  the  further  observation  that  the  quickest  and  least 
irritating  method  of  emptying  the  uterus  is  by  abdominal  and  uterine 
incision,  has  led  to  a  trial  of  Cesarean  section  where  the  os  and  cervix  were 
tightly  closed  and  labor  pains  were  absent.  Hillmann 242  collects  and  reports 
40  cases  of  eclampsia  treated  by  Cesarean  operation.  Of  the  40  mothers,  21 
perished  and  19  recovered.  Of  the  41  children,  18  perished  and  23  recov- 
ered. In  7  cases  convulsions  recurred  after  the  operation.  Ohlshausen 243 
exhibited  to  the  Obstetrical  Society  of  Berlin  a  patient  whom  he  had  deliv- 
ered during  eclampsia  by  Cesarean  section.  Before  admission  to  the  hospital 
the  patient  had  fourteen  severe  convulsions,  which  ceased  after  delivery. 
Among  250  cases  of  eclampsia  brought  to  his  clinic,  Ohlshausen  had  seen 
but  3  in  which  he  considered  the  indications  for  Cesarean  operation  present. 
Convulsions  ceased  after  delivery  in  each  of  these  cases  :  one  patient  died 
six  hours  after  delivery  in  eclamptic  coma.  Averke  ^  reports  3  cases  of 
Cesarean  section  in  38  cases  of  eclampsia.  In  2  of  these  patients  convulsions 
ceased  entirely  after  delivery  ;  in  1  case  convulsions  returned  ;  2  of  these 
patients  perished  from  coma ;  1  recovered.  The  writer's  experience  in 
Cesarean  section  for  eclampsia  is  limited  to  2  cases.  The  first  was  admitted 
to  the  Jefferson  Maternity,  having  had  violent  convulsions  for  several  hours. 
She  had  tuberculosis  of  the  hip-joint  and  a  pelvis  so  highly  contracted  that 


242  AMERICAN    TEXT- BOOK    OF    OBSTETRICS. 

delivery  through  the  vagina  was  impossible.  When  admitted,  the  patient 
was  apparently  moribund,  and  the  Cesarean  section  was  performed  virtually 
as  a  postmortem  operation.  The  patient  rallied,  became  conscious,  and  died 
several  days  after  the  operation.  Autopsy  revealed  highly  advanced 
nephritis  with  amyloid  degeneration  of  the  liver.  The  wound  in  the  uterus 
was  healing  normally.  The  second  case  was  that  of  a  young  primipara, 
nearly  blind  from  toxic  retinitis,  seen  in  consultation.  The  induction  of 
labor  was  attempted  without  success.  The  cervix  was  tightly  closed,  and 
eliminative  treatment  and  the  use  of  chloral  failed.  As  a  last  resort  the 
uterus  was  emptied  by  section.  The  patient  was  seven  months  advanced  in 
pregnancy.  She  died  in  coma  from  respiratory  failure  six  hours  after  the 
operation.  In  neither  of  these  cases  did  the  child  survive.  In  the  second 
case  the  child  lived  for  several  hours. 

Duhrssen 245  advocates  vaginal  Cesarean  section  in  the  treatment  of 
eclampsia.  This  procedure  is  practically  an  extension  of  his  method  for 
securing  rapid  and  complete  dilatation  of  the  cervix  by  incision.  The  opera- 
tion is  performed  by  pulling  down  the  cervix,  incising  the  anterior  vaginal 
wall,  and  pushing  aside  the  tissues  until  the  anterior  wall  of  the  cervix  is 
free  to  the  internal  os  ;  an  incision  is  then  carried  along  the  anterior  Avail  of 
the  cervix  into  the  lower  uterine  segment,  and  the  fetal  membranes  are  rup- 
tured. Version  is  then  made,  and  the  fetus  extracted.  Incision  is  prolonged 
to  permit  the  extraction  of  the  head.  The  placenta  is  then  removed,  the 
uterus  is  tamponed  with  gauze,  and  the  tissues  are  closed  with  catgut  suture. 

The  mortality  of  eclampsia  and  its  frequency  vary  greatly  under  different 
circumstances.  Bayer246  reports  50  cases  in  4250  births,  and  of  these,  53 
were  twin  pregnancies.  One  case  of  eclampsia  occurred  in  85  labors.  In 
the  statistics  of  63,281  labors  in  the  municipal  report  of  Cologne,  he  found 
39  cases  of  eclampsia  recorded.  Eighty-six  per  cent,  of  his  cases  were  in 
primipara;  and  12  per  cent,  in  twin  pregnancy.  In  20  per  cent,  the  con- 
vulsions occurred  during  pregnancy  ;  in  58  per  cent,  at  the  beginning  of 
labor  ;  and  in  22  per  cent,  during  the  puerperal  period.  His  mortality 
reached  24  per  cent.,  and  was  much  greater  in  cases  of  eclampsia  occurring 
during  pregnancy  than  in  those  in  which  the  convulsions  began  after  the 
advent  of  labor.  Two  of  his  cases  became  insane  and  died  in  an  asylum. 
Of  the  56  children,  15  were  stillborn,  12  died  soon  after  delivery,  and  31 
recovered.  His  method  of  treatment  was  that  usually  employed,  including  3 
Cesarean  operations:  2  performed  upon  the  dead  and  1  upon  a  patient  just 
about  to  perish.  It  was  not  considered  advisable  to  operate  early  in  any  of 
these  cases.  Stroganoff  reports  58  cases  of  eclampsia  without  death.247  In 
former  years  his  treatment  had  consisted  of  the  use  of  morphin  and  chloro- 
form, with  rapid  delivery  through  the  vagina.  He  modified  this  treatment 
by  substituting  the  inhalation  of  oxygen  whenever  possible,  and  giving  as 
little  chloroform  as  was  necessary  to  control  absolutely  the  convulsions. 
Morphin  was  injected,  and  any  manipulation  or  examination  of  the  genital 
organs  was  performed  under  chloroform  narcosis.     He  emptied  the  uterus 


THE  PATHOLOGY   OF  PREGNANCY.  243 

gradually,  without  rapid  and  forcible  dilatation.  Version  and  embryotomy 
were  the  chosen  methods  of  delivery,  preceded  by  the  introduction  of  the 
elastic  bag  for  gradual  dilatation.  Attention  was  given  to  maintaining  the 
action  of  the  heart,  to  cleansing  the  nostrils  and  throat  from  mucus,  and  to 
giving  the  patient  an  abundant  supply  of  fresh  air.  The  patient  was  given 
milk,  weak  tea,  brandy,  and  rectal  injections  of  salt  solution  or  of  milk. 
Aside  from  cleansing  the  skin  with  soap  and  warm  water,  no  effort  was  made 
to  induce  sweating  by  hot  baths  or  packs.  Pilocarpin  was  employed  in  some 
cases.     The  results  of  this  treatment  were  certainly  surprisingly  successful. 

Bolle,248  in  a  paper  before  the  Obstetrical  Society  of  Berlin,  draws  atten- 
tion to  a  disease  in  cows  exhibiting  the  symptoms  of  eclampsia.  It  is  seen 
in  well-nourished  fat  cattle,  where  the  birth  of  the  calf  has  been  easy.  The 
animals  are  seized  with  loss  of  appetite  and  restlessness,  followed  by  convul- 
sions, and  in  half  the  cases  with  albuminuria.  Paralysis  of  the  pneumo- 
gastric,  rapid  pulse,  and  inability  to  swalloAv  develop,  and  the  animals  die  of 
exhaustion.  Sensibility  is  greatly  increased,  but  the  temperature  remains 
normal  or  varies  but  little.  The  mortality  varies  from  40  to  66  per  cent., 
and  the  disease  usually  terminates  within  forty-eight  hours.  Upon  autopsy, 
edema  of  the  brain  and  lungs,  hemorrhages  in  the  liver,  and  parenchymatous 
nephritis  are  found.  These  cases  have  been  treated  by  morphin,  cold  appli- 
cations, chloral,  and  purgatives  without  much  success.  It  was  finally 
observed  that  these  animals  were  much  troubled  by  irritation  of  the  milk- 
glands,  and  accordingly  potassium  iodid  was  applied  by  injection.  The 
results  were  remarkably  good.  Following  this  analogy  Bolle,  in  Ohlshausen's 
clinic,  tried  the  injection  of  a  solution  of  potassium  iodid  into  the  mammary 
glands  in  cases  of  eclampsia.  In  IT  oases  so  treated  the  injections  were 
made  into  the  gland  itself  and  into  the  connective  tissue  below  the  clavicle. 
Two  of  these  patients  were  moribund  when  admitted  ;  15  recovered  and  1 
died. 

Glockner,2W  in  Zweifel's  Festschrift,  contributes  an  interesting  paper  upon 
the  treatment  and  statistics  of  eclampsia.  He  calls  attention  to  the  result 
of  the  conference  upon  eclampsia  at  the  Congress  of  Geneva  and  also  the 
recent  papers  of  Ohlshausen,  Lohlein,  Bidder  and  Diihrssen,  in  all  of  which 
the  treatment  of  eclampsia  by  narcotics  and  sedatives  is  to  be  retained  as  a 
cardinal  principle  and  the  uterus  is  to  be  emptied  only  when  absolutely 
necessary.  Zweifel,  at  Leipsic,  has  held  a  contrary  ground  for  some  years, 
maintaining  that  the  prompt  emptying  of  the  uterus  contributes  greatly  to 
the  patient's  recovery. 

The  mortality  of  eclampsia  is  variously  estimated.  It  is  possible  for  the 
mortality  to  sink  in  a  short  series  of  cases  to  4.5  per  cent.250  This  may  be 
followed  by  a  series  of  unfavorable  cases,  bringing  the  mortality  to  14.6  per 
cent.  A  mortality  rate  of  15  per  cent,  is  not  an  unfavorable  report  when 
the  character  of  the  disease  is  considered.  In  the  clinics  of  Dresden,  Halle, 
and  Konigsberg  the  mortality  of  eclampsia  has  been  30  per  cent.,  49  per 
cent.,  and  28   per  cent,   respectively.     Glockner  reports  the  results  of   the 


244  AM  ERIC  AX   TEXT-BOOK    OF    OBSTETRICS. 

treatment  of  143  cases  of  eclampsia  occurring  among  6902  labors  in  the 
Leipsic  clinic.  One  case  of  eclampsia  occurred  in  48.25  labors,  or  2.07  per 
cent,  of  frequency.  Twelve  per  cent,  of  these  patients  came  from  their 
homes  in  the  pregnant  condition,  14  per  cent,  were  in  the  first  stage  of  labor 
before  the  outbreak  of  eclampsia  when  admitted,  and  61.9  per  cent,  were 
brought  to  the  clinic  unconscious  in  eclampsia.  Ten  per  cent,  had  eclampsia 
but  were  conscious,  and  1  was  brought  to  the  hospital  dead  from  eclampsia. 
Eight  per  cent,  were  admitted  after  the  birth  of  the  child.  Eighty  per  cent, 
were  primiparas  and  56  per  cent,  were  between  the  ages  of  twenty -one  and 
twenty-five  rears.  The  great  majority  were  at  the  tenth  month  of  preg- 
nancy, and  more  cases  occurred  during  the  month  of  March  than  in  any 
other  portion  of  the  year.  The  smallest  number  occurred  in  the  month  of 
October.  About  13  per  cent,  had  contracted  pelves,  and  the  great  majority 
were  seized  with  eclampsia  during  labor.  Eclampsia  was  ushered  in  by 
severe  headache  in  73  per  cent,  of  cases.  In  only  30  did  labor  begin  spon- 
taneously, whereas  in  the  great  majority  it  was  necessary  to  bring  on  active 
labor.  The  operative  treatment  of  these  cases  consisted  in  dilating  the 
cervix  with  elastic  bags  or  by  incision  and  in  the  use  of  forceps,  version,  and 
embryotomy.  Postmortem  Cesarean  section  was  performed  once.  In  34 
per  cent,  there  was  no  convulsion  after  labor.  In  33  cases  bleeding  was 
practised,  and  in  17  morphin  was  given.  The  mortality  was  17.24  per  cent. 
Autopsy  disclosed  lesions  of  the  liver  in  76.9  per  cent.,  pneumonia  in  57.7 
per  cent.,  edema  of  the  lungs,  edema  of  the  brain,  and  other  lesions.  The 
mortality  from  puerperal  septic  infection  was  0.6S  per  cent.  Of  the  children, 
56.41  per  cent,  survived  and  43.59  per  cent,  perished.  This  series  may  be 
fairly  taken  to  represent  the  favorable  result  in  a  large  number  of  cases 
treated  by  modern  methods.  We  have  here  not  the  trial  of  Cesarean  sec- 
tion, but  the  practice  of  the'clinic  limited  to  the  usual  methods  of  delivery. 

The  writer's  study  and  experience  lead  him  to  the  following  conclusions 
regarding  eclampsia  :  The  theory  of  toxemia  from  deficient  action  of  elimi- 
nating organs  bears  the  test  of  success  in  prophylactic  treatment.  That 
method  of  diagnosticating  toxemia  that  relies  upon  the  study  of  the  quan- 
tity of  solids  excreted,  the  amount  of  urea,  and  the  presence  or  absence  of 
kidney  debris,  with  a  study  of  the  clinical  symptoms,  is  most  successful. 
Serum-albumin  cannot  be  depended  upon  as  the  principal  indication  of 
dangerous  toxemia.  Practically,  if  pregnant  patients  are  kept  under  com- 
petent medical  observation,  eclampsia  is  as  preventable  as  is  puerperal  septic 
infection.  The  treatment  of  toxemia  in  preventing  eclampsia  is  as  successful 
as  is  the  practice  of  antisepsis  in  preventing  puerperal  septic  infection. 

In  the  presence  of  eclampsia,  convulsions  should  be  controlled,  elimina- 
tion stimulated,  and  the  uterus  emptied.  Chloroform  and  oxygen  are  to  be 
used ;  ether  should  be  employed  for  prolonged  operations,  and  oxygen  freely 
given  by  inhalation.  To  promote  elimination  the  hot  packr  copious  lavage 
of  the  intestine  with  normal  salt  solution,  washing  out  the  stomach  and 
placing  within  the  stomach  calomel  and  soda,  the  intravenous  injection  of 


THE   PATHOLOGY    OF  PREGNANCY.  245 

normal  salt  solution,  or  hypodermoclysis,  are  the  most  reliable  means.  If 
rapid  purgation  is  necessary,  croton  oil  may  be  employed. 

To  subdue  convulsions  and  favor  the  dilatation  of  the  cervix  tincture  of 
veratrum  viride  injected  hypodermically  may  be  used  to  the  greatest  advan- 
tage.    Chloral  hydrate  given  by  rectal  injection  is  second  in  value. 

When  labor  begins  actively,  the  cervix  should  be  dilated  or  incised 
and  the  fetus  extracted  in  the  most  available  manner.  When  the  circum- 
stances are  favorable  and  the  cervix  cannot  readily  be  opened,  Cesarean 
section  may  be  performed.  If  the  mother  is  dead,  Cesarean  section  affords 
the  quickest  method  of  delivering  the  child.  It  is  especially  important  that 
patients  surviving  eclampsia  should,  if  possible,  be  rescued  from  pneumonia, 
which  so  often  results  fatally.  Atropin  given  hypodermically  tends  to  pre- 
vent pulmonary  edema,  while  the  free  use  of  oxygen,  well-ventilated  rooms, 
and  rectal  injections  of  milk  and  whisky  help  to  prevent  death  from  pneu- 
monia. After  delivery,  strychnin  may,  if  necessary,  be  used  as  a  tonic  with- 
out especial  danger  of  a  return  of  the  convulsions. 

The  mortality  of  eclampsia  depends  upon  the  promptness  and  thorough- 
ness of  the  treatment  employed.  Each  convulsion  greatly  increases  the 
mortality. 

In  the  treatment  of  eclampsia  the  writer  cannot  commend  pilocarpi]!, 
large  doses  of  morphin,  bleeding,  profound  and  prolonged  anesthesia,  and 
rapid  emptying  of  the  uterus  when  no  attempt  at  spontaneous  labor  is 
present. 

Disorders  of  the  Nervous  System  in  the  Pregnant  Patient. — Neu- 
ralgia.— The  pregnant  patient  is  peculiarly  susceptible  to  various  disorders 
of  the  nervous  system.  Among  these  affections  the  most  common  are  the 
various  forms  of  neuralgia  occasioning  great  distress,  often  observed  during 
gestation.  As  is  generally  the  case,  these  neuralgias  have  as  a  starting- 
point  some  portion  of  the  nervous  system  in  which  a  pathological  con- 
dition is  present.  The  decay  of  the  teeth,  so  often  observed  during  preg- 
nancy, accounts  for  many  of  the  cases  of  obstinate  toothache  that  annoy  and 
distress  these  patients.  In  women  who  suffer  from  habitual  constipation 
during  pregnancy  and  in  whom  the  size  of  the  fetus  is  so  great  as  to  cause 
pressure  upon  the  nerve-trunks  at  the  brim  of  the  pelvis,  obstinate  cramp  and 
sciatic  pain  may  occasion  great  distress  and  may  seriously  affect  the  patient's 
general  health.  Some  of  the  severest  of  these  cases  result  from  the  pressure 
of  hardened  fecal  matter  upon  nerve-trunks  above  the  brim  of  the  pelvis, 
and  upon  branches  of  nerves  so  situated  that  they  may  be  pressed  upon  in 
the  pelvic  cavity.  In  some  of  these  cases  the  uterus  will  be  found  retro- 
verted,  thus  preventing  proper  evacuation  of  the  bowels  and  adding  to 
the  pressure  that  retained  fecal  matter  excites.  In  other  cases  the  patients 
complain  of  cramp  and  of  sudden  spasmodic  contraction  of  the  muscles  of 
the  thigh,  often  becoming  worse  at  night.  When  the  disorder  is  severe,  ob- 
stinate pain,  radiating  down  the  thigh  as  far  as  the  knee  or  even  below  the 
knee,  is  often  observed. 


246  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

In  dealing  with  these  cases  the  first  duty  of  the  obstetrician  is  to  ascer- 
tain the  precise  position  of  the  uterus  :  if  it  be  found  retroverted  and  not 
bound  down  by  adhesions,  it  is  a  comparatively  simple  matter  to  raise  it  to 
or  above  the  brim  of  the  pelvis,  and  to  sustain  it  by  tampons  of  carded  wool. 
If  the  uterus  be  found  bound  down  by  adhesions,  the  problem  is  much  more 
difficult.  If  the  patient  be  put  at  rest  in  bed  and  the  bowels  be  moved  thor- 
oughly by  salines,  a  very  efficient  form  of  tampon  in  these  cases  consists  of  a 
strip  of  sterile  surgeon's  lint  three  or  four  inches  wide,  thoroughly  saturated 
with  glycerin.  A  Sims  speculum  is  introduced,  and,  with  the  aid  of  dressing- 
forceps,  this  strip  is  packed  closely  behind  the  cervix,  pushing  the  uterus  up 
as  far  as  possible  without  causing  positive  pain.  This  application  is  followed 
by  a  very  copious  discharge  of  watery  mucus,  greatly  relieving  congestion 
and  softening  adhesions,  which  are  not  very  tenacious.  The  growth  and 
development  of  the  uterus  will  frequently  separate  such  adhesions,  and  sur- 
prisingly good  results  are  observed  in  cases  in  which  the  uterus  has  been 
partially  bound  down  in  the  pelvis.  The  existence  of  pregnancy  naturally 
contraindicates  uterine  massage  and  any  instrumental  interference. 

If  the  uterus  lies  in  a  good  position,  the  next  step  to  be  taken  in  relieving 
pelvic  pain  radiating  down  the  thighs  is  to  empty  the  bowel  thoroughly ;  in 
doing  this  the  same  care  should  be  exercised  as  in  preparing  a  patient  for  an 
abdominal  section.  In  addition  to  the  purgatives  usually  employed,  the 
colon  should  be  flushed  thoroughly  by  frequent  and  copious  injections  of 
warm  water  and  magnesium  sulphate,  or  injections  containing  soapsuds  and 
castor  oil,  to  which  turpentine  is  added.  If  the  feces  are  impacted,  an  ounce 
of  ox-gall  dissolved  in  a  quart  of  hot  soapsuds  should  be  injected  through 
a  rectal  tube  as  high  into  the  bowel  as  possible.  The  patient  should  retain 
this  as  long  as  possible,  and  when  an  inclination  to  evacuate  the  bowels 
arises,  a  second  injection  of  magnesium  sulphate,  glycerin,  and  turpentine 
will  usually  result  in  success.  Many  cases  of  obstinate  pelvic  neuralgia  occur- 
ring during  pregnancy  are  cured  by  emptying  the  bowel  of  hard  and  irri- 
tating feces. 

If,  when  the  uterus  is  in  proper  position  and  the  intestine  is  free  from 
fecal  matter,  the  pelvic  neuralgia  still  persists,  it  will  be  found  to  depend 
upon  anemia,  depressing  causes  that  affect  the  nervous  svstem,  or,  possibly, 
upon  malarial  infection.  Treatment  appropriate  for  this  condition  will  result 
in  the  gradual  relief  of  the  neuralgia. 

Facial  neuralgia  with  hemicrania  is  often  observed  in  pregnant  patients 
in  whom  no  exciting  cause,  as  decayed  teeth,  can  be  discovered.  Many 
attacks  follow  exposure  to  cold  or  to  damp  ;  others  are  caused  by  loss  of 
sleep.  The  pain  is  often  paroxysmal,  and  frequently  an  irregular  interval 
may  be  observed  between  the  attacks  ;  thus,  some  patients  will  sleep  during 
the  night,  but  are  seized  with  violent  pain  in  the  early  morning;  in  others 
the  suffering  increases  in  the  afternoon  or  at  night.  The  face  and  the  scalp 
are  often  tender  to  pressure  in  these  cases,  and  the  conjunctivae  on  the  affected 
side  frequently  ai-e  reddened. 


THE   PATHOLOGY    OF  PREGNANCY.  247 

When  painful  spots  can  be  isolated,  local  treatment  may  be  instituted  by 
painting  the  part  with  menthol  or  with  iodin,  or  by  spraying  it  with  ether  or 
with  some  other  anesthetic.  The  constitutional  treatment  of  this  condition 
consists  in  thoroughly  emptying  the  intestine  to  relieve  the  patient  of  the 
fecal  poison  that  may  be  depressing  the  nervous  system.  Absolute  rest  in  a 
darkened,  warm  room  of  equable  temperature,  systematic  feeding  of  easily 
digested  food,  and  tonics — iron,  arsenous  acid,  and  quinin — and,  if  the  pain 
be  severe,  alcohol,  at  regular  intervals,  are  to  be  recommended.  When,  by 
reason  of  pain,  sleep  is  impossible,  phenaeetiu  with  caffein  and  sodium  bicar- 
bonate is  often  used  to  advantage.  If  pelvic  neuralgia  is  present,  phenace- 
tin  may  be  given  by  rectal  suppositories  of  10  grains  each.  Morphia  and 
atropin  may  be  given  hypodermically  when  other  remedies  fail.  Chloral  and 
the  bromids  are  of  comparatively  little  value  and  often  disappoint  in  these 
cases.  The  patient  should  be  told  that  the  less  opium  she  takes  the  sooner 
she  will  recover ;  and  where  her  suffering  is  not  severe,  every  effort  should 
be  made  to  improve  her  general  condition  by  tonic  treatment  rather  than  by 
narcotizing  her  with  opium. 

Polyneuritis  in  pregnancy  has  been  observed  after  parotitis.  Gallavar- 
din201  reports  the  case  of  a  primipara  who,  when  eight  months  pregnant,  had 
double  parotitis.  On  the  eighth  day  of  the  disease  itching  and  burning 
occurred  over  the  whole  body,  with  pain,  paresis,  and,  finally,  paralysis.  The 
abdomen  became  greatly  distended,  and  the  patient's  strength  suddenly  began 
to  fail.  Labor  was  at  once  induced,  and  the  child  was  delivered  by  forceps. 
It  perished  soon  after  birth.  The  patient  made  a  slow  recovery.  It  is  of 
interest  to  note  that  after  the  development  of  the  neuritis  she  ceased  to  feel 
fetal  movements. 

The  reflex  excitability  to  electricity  that  pregnant  patients  display  is  de- 
scribed by  Tridondani.232  He  made  an  elaborate  series  of  tests  of  all  the 
available  nerve-trunks  in  the  pregnant  patient,  and,  recognizing  the  variation 
in  individuals,  he  was  able  to  conclude  in  general  as  follows  :  that  general 
superficial  reflex  sensibility  is  diminished  during  pregnancy,  with  the  excep- 
tion of  the  surface  of  the  abdomen,  where  it  is  distinctly  increased,  and 
especially  in  primiparas.  The  patellar  reflex  is  usually  increased ;  in  some 
cases  the  pupil  of  the  eye  was  found  in  a  condition  approaching  that  described 
as  the  Argyll  Robertson  pupil.  The  excitability  to  electrical  stimulation  with 
the  faradic  current  is  somewhat  lessened  during  pregnancy  in  these  patients. 
Variations  in  excitability  do  not  depend  so  much  upon  pritniparity  or  multi- 
parity  as  upon  the  existence  of  pregnancy  and  the  general  condition  of  the 
patient.  When  variations  in  excitability  occur,  they  usually  disappear  about 
ten  days  after  the  birth  of  the  child. 

Tarnier253  summarizes  the  influence  of  neuroses  on  pregnancy  and 
labor. 

Hysteria  is  rarely  influenced  favorably  by  pregnancv.  Hysterical  mani- 
festations rarely  disappear  during  pregnancy,  although  sometimes  they  are 
considerably  inci'eased.     As  Landouzy  has  shown,  hysteria  is  usually  aggra- 


248  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

vated  by  pregnancy.     Hysteria  does  not  seriously  complicate  pregnancy  or 
gestation  :  it  does  not  provoke  abortion  or  premature  labor. 

As  regards  epilepsy,  in  one-fourth  of  the  cases  that  Tarnier  observed  the 
patient  was  uninfluenced  by  pregnancy.  In  another  fourth  the  epilepsy  was 
aggravated,  and  death  occasionally  happened  from  a  series  of  epileptic  con- 
vulsions. In  the  remaining  half  epilepsy  seemed  less  severe  than  usual 
during  pregnane}'.  This  may  be  due  to  the  cessation  of  menstruation,  as 
menstruation    often  provokes  epileptic  attacks. 

The  differential  diagnosis  of  epilepsy  from  eclampsia  is  an  interesting 
one.  The  examination  of  the  excretions  of  the  patient  is  absolutely  neces- 
sary for  an  accurate  diagnosis.  If  obtainable,  the  history  should  be  of  con- 
siderable aid. 

Tarnier  regards  chorea  as  an  especially  dangerous  neurosis  during  preg- 
nancy. Its  mortality  has  been  variously  estimated  at  from  28  to  30  per 
cent.  In  20  per  cent,  abortion  or  premature  labor  occurred.  Many  of  these 
patients  were  rheumatic  or  chlorotic  before  pregnancy. 

Salivation. — Derangement  of  various  secretory  nerves  is  sometimes 
observed  during  gestation  :  the  salivation  of  pregnane}'  is  a  familiar  instance. 
Hypersecretion  of  tears  is  seen  in  patients  suffering  from  salivation,  as  shown 
in  a  case  reported  by  Neiden.254  The  secretion  was  so  abundant  that  the  eyes 
were  continually  suffused,  and  gave  rise  to  an  eczematous  eruption  of  the  lids. 
The  tear  secretion  was  weakly  alkaline,  the  eyes  were  normal,  and  no  ajipre- 
ciable  cause  was  found  for  the  condition.  The  patient  was  cured  finally 
by  the  injection,  into  the  eye,  of  a  5  per  cent,  cocain  solution.  Salivation  of 
pregnancy  is  a  most  obstinate  and  annoying  condition,  often  repeated  in  sub- 
sequent pregnancies,  and  resisting  all  forms  of  treatment.  It  arises  without 
apparent  cause,  and  usually  affects  women  of  nervous  temperament,  espe- 
cially if  the  general  health  is  depressed.  Treatment  is  usually  palliative 
only,  and  it  should  consist  in  the  free  administration  of  tonics  and  in  those 
milder  sedatives  that  interfere  least  with  the  patient's  nutrition.  The  bromids 
have  been  given  freely  both  by  the  stomach  and  by  spray  applied  to  the 
interior  of  the  mouth.  The  effort  may  be  made  to  cocainize  the  mucous 
membrane  near  the  opening  of  Steno's  duct  by  spraying  cocain  into  the 
mouth.  The  condition  rarely  if  ever  becomes  serious.  Another  form  of 
abnormal  secretion  occurring  in  pregnancy  is  that  of  excessive  perspiration, 
which  is  commonly  met  with  in  poorly  nourished  and  neurasthenic  cases. 

Herpes  is  among  the  interesting  disorders  of  the  nervous  system  to  which 
the  pregnant  patient  is  liable.  Founder255  reports  a  case  in  which  the, 
lesions  were  distributed  irregularly  over  the  body,  especially  upon  the  fore- 
arms, the  anterior  part  of  the  thorax  and  feet,  and  the  abdomen.  Accom- 
panying these  lesions  were  patches  of  redness,  in  some  instances  these  areas 
being  covered  with  bulla;  as  large  as  an  olive  or  a  small  cherry.  The  period 
of  pregnancy  at  which  this  disorder  usually  occurs  is  between  the  third  and 
the  fifth  month,  occasionally  as  late  as  the  sixth  or  the  eighth  month.  More 
rarely  the  lesion  does  not  present  itself  until  the  second  or  the  third  day  of 


THE  PATHOLOGY   OF  PREGNANCY.  249 

the  puerperal  period.  This  disorder  manifests  a  strong  tendency  to  recur 
during  subsequent  pregnancies,  and  instances  are  given  in  which  the  patient 
has  suffered  from  herpes  during  five  successive  gestations.  Although  intol- 
erable itching  and  burning  accompany  herpes  during  pregnancy,  yet  the 
general  health  remains  remarkably  unaffected.  The  occurrence  of  gestation 
is  not  influenced  by  this  complication,  and  patients  usually  recover  promptly 
when  gestation  terminates.  In  the  puerperal  period  herpes  is  often  charac- 
terized during  its  onset  by  fever,  perspiration,  and  general  pruritus.  In  from 
twenty  to  twenty-four  hours  after  these  symptoms  occur  the  characteristic 
eruption  appears.  The  remarkable  tendency  of  herpes  to  recur  is  illustrated 
by  the  cases  of  Cottle,  Wilson,  Gale,  and  Hardy,  the  last  of  whom  describes 
a  patient  who  suffered  from  this  disorder  in  9  out  of  10  pregnancies. 

There  is  no  evidence  that  the  fetus  and  its  appendages  are  affected  in  this 
disease.  Mixed  forms  of  the  eruption  are  seen  occasionally,  some  of  them 
resembling  pemphigus  and  others  assuming  a  syphiloid  type.  It  is  noticed 
that  young  women  are  attacked  by  herpes  in  preference  to  older  ones. 

The  treatment  of  herpes  consists,  first,  in  properly  regulating  the  functions 
of  the  body.  Herpetic  patients  ai-e  generally  depressed  or  in  some  manner 
are  deficient  in  nervous  energy,  and  they  will  be  found  to  improve  under  the 
prolonged  use  of  arsenic,  hypophosphites,  and  iron.  The  many  remedies 
that  have  been  administered  as  specifics  in  this  disorder  and  their  failure  to 
influence  the  course  of  the  disease  show  that  it  is  not  amenable  to  specific 
treatment.  When  the  eruption  first  appears,  borated  vaselin,  glycerol  of 
starch,  and  lime-water  and  oil  will  be  found  to  be  soothing  applications. 
When  the  eruption  is  fully  developed,  bismuth  and  starch  and  starch  and 
talcum  are  useful  dressings.  For  the  intolerable  itching,  applications  of 
carbolic  acid,  chloral  hydrate,  menthol,  or  corrosive  sublimate  in  solution 
have  been  found  useful.  When  a  large  portion  of  the  body  is  involved, 
baths  containing  starch,  gelatin,  or  bran  may  be  employed. 

Although  the  prognosis  of  herpes  complicating  gestation  is  favorable  so 
far  as  the  continuance  of  pregnancy  is  concerned,  still  this  complication 
exercises  a  most  depressing  influence  and  may  lead  to  complicated  labor  by 
reason  of  exhaustion.  Care  should  be  taken,  then,  to  support  the  general 
strength  of  the  patient  in  every  possible  wajT,  to  promote  nutrition  by  a 
carefully  ordered  diet  and  the  persistent  use  of  tonics,  and  to  conserve  the 
patient's  strength  during  labor  in  every  possible  manner. 

Sudden  death  during-  pregnancy  may  result  from  the  entrance  of  fluid 
or  of  air  into  the  enlarged  sinuses  of  the  uterus.  Hektoen 25B  narrates  the 
case  of  a  patient  who  fell  dead  while  taking  a  vaginal  injection  ;  it  was  found 
that  she  had  been  using  a  Davidson  syringe.  The  autopsy  showed  the  tis- 
sues of  the  uterus  filled  with  air  and  blood  and  the  placenta  partially  detached, 
while  the  right  ventricle  contained  frothy  blood  but  no  clot.  Air  was  found 
in  the  subserous  vessels  and  also  in  the  vessels  of  the  pericardial  and  pleural 
cavities. 

The  existence  of  pregnancy  seems  to  predispose  to  sudden  respiratory  and 


250  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

heart  failure.  This  is  especially  the  case  when  nausea  and  vomiting  have 
been  well  marked  during  the  first  months  of  pregnancy.  McCabe257  reports 
the  case  of  a  patient  who  desired  relief  from  obstinate  nausea  and  vomiting 
and  to  whom  morphin  had  been  given  by  hypodermic  injection.  As  it  was 
impossible  for  the  attending  physician  to  see  her  at  short  intervals,  a  hypo- 
dermic injection  was  prepared  by  him  and  left  for  administration  during  his 
absence.  She  seemed  relieved,  but  a  few  days  aftei',  on  attempting  to  move, 
a  sudden  weakness  developed,  terminating  almost  immediately  in  death. 

The  same  observer  describes  the  case  of  a  young  woman  who  during  her 
second  pregnancy  was  much  annoyed  by  intense  pain  over  the  uterus  and 
across  the  lower  part  of  the  back,  simulating  after-pains.  A  hypodermic 
injection  of  \  of  a  grain  of  morphin  was  given,  which  gave  relief.  It  was 
found  that  she  had  miscarried  the  night  before  at  about  two  and  a  half 
months  of  gestation.  There  was  no  sign  of  puerperal  septic  infection,  but  a 
rapid  and  weak  heart  gave  rise  to  much  distress.  During  the  following  night 
she  suddenly  sprang  from  her  bed  and  almost  immediately  expired. 

As  in  both  the  foregoing  cases  morphin  had  been  given  by  hypodermic 
injection,  the  relation  borne  by  this  drug  to  the  phenomena  observed  is  of 
interest.  From  these  cases  it  would  seem  that  morphin  administered  hypo- 
dermically  to  pregnant  patients  is  a  dangerous  remedy. 

Vinay 25S  assigns  the  following  as  causes  for  sudden  death  observed  during 
or  after  labor  :  embolism  of  the  right  heart  and  pulmonary  artery  ;  entrance 
of  air  into  the  veins  ;  syncope  and  shock  ;  cardiac  lesions  and  rupture  of 
aneurysmal  sacs  ;  cerebral  and  meningeal  hemorrhages  ;  severe  hemoptysis 
and  hematemesis  ;  pleuritic  effusions  ;  and  rupture  of  large  abscesses,  such  as 
hepatic  abscess.  Of  these  causes  the  most  common  is  embolism  of  the  pul- 
monary artery,  most  frequently  seen  in  anemic  patients  and  multiparas  The 
symptoms  rarely  appear  before  the  tenth  day,  the  dangerous  period  extending 
from  the  fourteenth  to  the  twenty-fourth  day.  Very  slight  exertion  may  be 
sufficient  to  bring  about  a  fatal  issue. 

Lesions  of  the  heart  rarely  are  dangerous  when  compensated,  but  when 
the  heart  muscle  is  diseased,  the  mechanical  disturbances  following  pi-egnancy 
may  bring  on  death  at  any  time. 

Zweifel  ^  has  collected  and  reports  a  number  of  cases  in  which  sudden 
death  followed  embolism  of  the  pulmonary  artery,  valvular  heart  disease, 
tumor  of  the  spinal  cord,  stenosis  of  the  arteries,  and  craniotomy  performed 
upon  a  woman  who  had  suffered  from  bronchitis  during  pregnancy. 

Cerebral  thrombosis  and  hemorrhage  during  pregnancy  are  illustrated 
in  a  case  reported  by  Horrocks,260  in  which  a  patient  during  her  second  preg- 
nancy developed  stupor  and  drowsiness,  with  rectal  and  vesical  incontineuce, 
during  the  last  month  of  gestation.  The  pupils  were  normal,  and  symptoms 
of  palsy  were  absent.  The  urine  contained  neither  albumin  nor  sugar.  The 
heart  appeared  to  be  normal,  and  labor  subsequently  came  on  spontaneously. 
Consciousness,  however,  was  obscured,  and  derangement  in  the  motor  appa- 
ratus of  the  brain  and  nervous  system  was  present.     After  death,  many  of 


THE  PATHOLOGY   OF  PREGNANCY.  251 

the  cerebral  veins  were  found  occluded  by  thrombi.  There  was  also  recent 
extravasation  of  blood  along  the  internal  capsule.  Cystitis  and  suppura- 
tive nephritis  on  one  side  existed. 

Meningitis  during  pregnancy  is  almost  invariably  fatal  to  the  mother  and 
frequently  to  her  child.  Chambrelent 261  describes  7  cases  of  acute  meningitis 
during  pregnancy,  in  6  of  which  pregnancy  was  terminated  artificially  with 
the  birth  of  a  living  child.  In  1  case  birth  was  spontaneous  before  the 
mother's  death.  In  view  of  the  grave  nature  of  this  complication,  labor 
should  be  induced  in  cases  of  meningitis  during  pregnancy  when  the  fetus  is 
viable,  in  the  hope  of  saving  the  life  of  the  infant. 

Verstraete 262  describes  the  case  of  a  pregnant  woman,  aged  seventeen, 
suffering  from  meningitis.  She  Avas  delivered  a  few  hours  after  entering  the 
hospital,  and  died  twenty  hours  after  the  birth  of  the  child.  Upon  autopsy, 
pneumococci  were  found  in  the  meninges  but  were  absent  from  the  lungs. 
There  was  no  pneumonia,  and  no  secondary  lesions  were  found.  Double 
pyelitis  was  present  with  streptococci,  but  there  were  no  pneumococci. 

Spinal  Irritation  Complicating  Pregnancy  and  Labor. — The  hyper- 
emia and  hyperesthetic  condition  characterizing  pregnancy  exaggerates  all 
forms  of  functional  nervous  disturbances  or  pathological  conditions  in  the 
nervous  system.  Spinal  irritation  is  not  infrequently  observed,  and  it  is  well 
illustrated  by  cases  reported  by  Napier.263  In  these  there  was  great  tender- 
ness on  pressure  along  the  spines  of  the  vertebrae,  and  in  one  patient  fatal 
albuminuria  gradually  developed.  These  cases  followed  an  epidemic  of 
diphtheria  that  prevailed  four  or  five  years  prior  to  these  observations  :  the 
poison  of  diphtheria  seemed  to  lose  its  activity  by  attenuation.  Cases  of 
cerebrospinal  meningitis  developed  as  the  epidemic  subsided,  and  last  of  all 
occurred  the  cases  of  pregnancy  complicated  by  great  tenderness  along  the 
spine  ;  this  tenderness  seriously  impaired  the  patient's  strength  and  delayed 
convalescence.  A  toxic  condition  following  wide-spread  diffusion  of  diph- 
theric poison  should  be  considered  as  the  cause  of  these  cases,  but  the  phe- 
nomena of  spinal  irritation  were  predominant. 

Maternal  impressions  are  familiar  to  all  obstetricians  of  extensive  read- 
ing and  wide  experience.  It  is  not  the  writer's  purpose  to  consider  the 
matter  in  detail,  but  simply  to  draw  attention  to  the  fact  that  a  pregnant 
patient  may  undoubtedly  be  so  profoundly  influenced  by  nervous  shock  as 
very  markedly  to  alter  the  development,  the  shape,  the  size,  and  the  appear- 
ance of  her  offspring.  In  recent  literature  on  the  subject  Mackay 2<M  describes 
5  cases  in  which  fright  produced  distinct  birth-marks  upon  the  fetus.  The 
writer  may  cite  a  case  under  his  personal  observation  in  which  a  pregnant 
woman  was  informed  that  an  intimate  friend  had  been  killed  suddenly  by 
being  thrown  from  his  horse ;  the  immediate  cause  of  death  was  fracture  of 
the  skull,  produced  by  the  corner  of  a  dray  against  which  the  rider  was 
thrown.  The  woman  was  profoundly  impressed  by  the  circumstance,  which 
was  described  to  her  minutely  by  an  eye-witness.  At  birth  her  child  pre- 
sented a  red  and   sensitive  area   upon   the  scalp  corresponding  in   location 


252  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

exactly  with  the  situation  of  the  fatal  injury  in  the  rider.  The  child  lias 
now  reached  womanhood,  and  this  area  upon  the  scalp  remains  red  and  sensi- 
tive to  pressure,  and  is  almost  devoid  of  hair. 

The  subject  of  maternal  impressions  does  not  require  discussion  here. 
There  is  certainly  more  than  mere  coincidence  in  the  fact  of  fright  and  shock 
and  the  subsequent  malformation  or  marking  of  the  fetus.  The  well-known 
"elephant  man"  of  England,  and  the  "turtle  man"  exhibited  in  the  United 
States,  with  other  instances,  are  familiar  evidences  of  this  anomaly. 

Chorea  during  Pregnancy. — There  is  no  disorder  of  the  nervous  system 
so  manifestly  aggravated  by  pregnancy  as  chorea.  The  physiological  plethora 
characteristic  of  normal  pregnancy  seems  to  exaggerate  the  functional  activity 
of  the  nervous  system,  and  results  in  marked  exacerbation  of  all  pathological 
phenomena.  The  characteristic  choreic  movements  occasionally  extend  even 
to  the  uterus,  as  in  a  case  reported  by  Braxton  Hicks.265  The  patient  was  a 
young  woman  who  had  suffered  from  chorea  in  childhood  ;  the  uterus,  which 
could  be  outlined  distinctly  in  the  abdomen,  presented  marked  alterations  of 
form,  accompanied  by  very  evident  choreic  contractions.  These  uterine 
movements  became  less  violent  as  the  patient  was  treated  by  rest  in  bed  and 
by  the  administration  of  arsenic ;  she  was  subsequently  delivered  in  normal 
labor,  making  a  good  recovery. 

In  an  elaborate  essay  upon  the  subject  McCann  -m  divides  cases  of  chorea 
occurring  in  pregnant  patients  into  cases  of  true  chorea,  of  hysterical  chorea, 
and  a  mixed  form.  It  is  rare  to  find  chorea  occurring  in  patients  after  the 
eighteenth  year  except  during  pregnancy.  Primigravidse  are  more  susceptible 
to  chorea,  especially  to  true  chorea,  than  are  multigravidae.  In  patients  free 
from  rheumatism  it  is  rare  for  true  chorea  to  occur  in  any  but  the  first  preg- 
nancy. When  the  exaggerated  reflex  condition  that  occurs  in  chorea  is 
called  to  mind,  it  is  natural  to  expect  that  the  great  majority  of  cases  will 
occur  during  the  third  and  fourth  months  of  gestation.  The  reason  for  this 
seems  to  be  the  irritating  effect  upon  the  nervous  system  of  fetal  movements, 
which  begin  to  be  felt  at  about  that  time.  So  far  as  the  etiology  of  chorea  in 
pregnancy  is  concerned,  acute  rheumatism  is  the  most  immediate  cause,  a 
hereditary  history  of  distinct  rheumatic  taint  being  next  in  frequency.  Epi- 
lepsy and  other  disorders  of  the  nervous  system  predispose  to  chorea  during 
pregnancy.  Fright,  emotion,  and  profound  anemia  also  favor  its  occurrence. 
For  the  actual  outbreak  of  chorea,  however,  hysterical  predisposition  to  ner- 
vous excitability,  a  depreciated  condition  of  the  blood,  and  an  actively  exciting 
cause,  which  is  usually  found  in  fetal  movements,  must  be  present.  Post- 
mortem examinations  of  patients  who  have  died  from  chorea  during  preg- 
nancy show  that  in  severe  cases  the  motor  coi'tex,  the  intellectual  centers, 
and  the  spinal  cord  are  involved.  In  mild  cases  the  motor  cortex  only  is 
implicated,  and  the  spinal  cord  least  often. 

The  effect  of  chorea  on  pregnancy  depends  entirely  upon  its  severity. 
In  mild  cases  amenable  to  treatment  pregnancy  is  not  interrupted,  whereas 
in  severe  cases  abortion  occurs,  sometimes  followed  by  fatal  termination  from 


THE   PATHOLOGY    OF  PREGNANCY.  253 

coma  and  high  temperature.  Severe  cases  of  chorea  that  do  not  result 
fatally  may  end  in  mania  persisting  for  a  considerable  time.  Paralysis  and 
delirium  are  also  occasionally  observed  to  follow  this  disorder.  If  the  preg- 
nancy is  at  term  when  the  woman  is  attacked  by  chorea,  the  risk  to  the 
child  is  but  very  slightly,  if  at  all,  increased.  The  earlier  in  pregnancy  that 
chorea  occurs,  the  greater  is  the  danger  to  the  fetus.  Although  the  physician 
naturally  hopes  that  choreic  movements  will  cease  after  delivery,  this  is  rarely 
the  case ;  they  subside  very  gradually,  and  they  have  been  observed  to  con- 
tinue for  five  months  after  labor.  Pregnancy  greatly  predisposes  to  the 
recurrence  of  chorea,  so  that  a  girl  who  has  been  choreic  in  early  life  will 
almost  certainly  again  develop  chorea  should  pregnancy  occur.  As  in  the 
non-pregnant,  chorea  during  pregnancy  is  sometimes  more  severe  than  a 
former  attack,  or,  again,  it  may  be  less  violent.  Chorea  during  childhood  is 
very  likely  to  reappear  in  subsequent  pregnancies  in  the  same  individual. 
It  is  also  interesting  to  note  that  the  younger  the  patient,  the  greater  is  the 
liability  to  a  recurrence  of  chorea. 

The  great  tendency  of  pregnant  patients  to  present  hysterical  manifesta- 
tions results  in  introducing,  to  a  very  perplexing  degree,  this  element  into 
cases  of  chorea  during  pregnancy.  The  differential  diagnosis  is  best  made 
from  the  character  of  the  movements,  which  in  hysteria  are  more  sudden 
and  occasionally  are  rhythmical  in  character.  Impairment  of  sensibility  is 
observed  as  a  jyrominent  symptom  in  cases  possessing  a  strong  hysterical 
element.  A  history  of  previous  hysteria  is  sometimes  obtainable.  In  making 
a  differential  diagnosis  simulated  movements  must  be  borne  in  mind,  as  they 
are  sometimes  calculated  to  deceive  skilled  observers.  As  regards  the  por- 
tion of  the  body  most  often  affected  by  choreic  movements,  Gowers,267  out 
of  64  cases,  found  11  in  which  the  right  side  only  was  affected,  and  13  in 
which  the  left  side  alone  was  affected.  Chorea  during  pregnancy  is  most 
often  bilateral,  the  reason  for  this  lying  in  the  fact  that  as  the  disease  is  more 
severe  than  in  the  non-pregnant,  its  manifestations  are  more  wide-spread.  In 
these  cases  it  is  usually  found  that  in  the  beginning  the  movements  were  uni- 
lateral, and  afterward,  as  the  disorder  inci-eased  in  severity,  became  bilateral. 
The  physiognomy  of  the  pregnant  patient  suffering  from  chorea  is  charac- 
teristic, being  listless  and  vacant  in  expression,  peculiar  grimaces  resulting 
when  the  facial  muscles  are  affected.  General  relaxation  of  the  muscular 
system  often  occurs  early  in  the  disease,  and  in  the  later  stages  mental  apathy 
is  not  infrequent.  Dilated  pupils  are  often  present,  and  are  thought  to 
depend  upon  a  generally  relaxed  condition  of  the  muscular  system.  In  a 
large  number  of  cases  the  face  is  affected  ;  in  a  few,  however,  it  is  not. 
Speech  and  the  movements  of  the  tongue  become  involved  in  the  severe 
cases.  Sighing  and  irregular  respiration  have  been  described  by  Romberg 
and  others.  It  is  interesting  to  note  that  chorea  involves  the  memory  of 
pregnant  patients  more  severely  than  it  does  that  of  the  non-pregnant.  The 
cessation  of  choreic  movements  is  promptly  followed  by  improvement  in 
memory.     Patients  who  become  maniacal  after  chorea  often  give  utterance 


254  AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 

to  a  peculiar  cry,  described  by  Romberg  and  others.  The  analogy  between 
the  cry  of  chorea  and  that  of  the  patient  about  to  be  seized  by  an  epileptic 
paroxysm  is  interesting.  The  prognosis  of  mania  or  delusions  complicating 
chorea  in  pregnancy  is  often  unfavorable ;  if  the  patient  does  not  exhibit 
chorea  after  her  delivery,  she  may  be  found  the  victim  of  delusions  or  of 
chronic  mental  apathy. 

The  symptoms  of  chorea  especially  referable  to  the  pregnant  state  are, 
first  in  importance,  those  produced  by  the  movements  of  the  fetus.  The 
presence  or  absence  of  a  nervous  temperament  in  a  choreic  patient  will  deter- 
mine the  severity  of  the  symptoms.  As  regards  the  influence  of  chorea  upon 
labor,  choreic  movements  often,  cease  when  labor-pains  set  in  ;  such  move- 
ments generally  subside  during  the  stage  of  uterine  contraction,  often  recur- 
ring as  soon  as  the  labor-pains  have  ceased.  The  labors  themselves  are  often 
normal,  and  in  many  cases  during  the  pains,  especially  when  the  patient 
endeavors  to  assist  them,  the  choreic  movements  become  more  than  usually 
pronounced.  Although  there  is  a  temporary  lull  in  the  choreic  movements 
after  the  birth  of  the  child,  the  effort  to  expel  the  placenta  is  usually  fol- 
lowed by  exacerbation.  It  occasionally  happens  that  choreic  movements 
become  more  than  usually  increased  during  the  puerperal  state,  at  about  the 
third  or  the  fourth  day.  The  irritation  incident  to  the  formation  of  milk 
has  been  cited  to  explain  this  fact.  Abdominal  pain,  which  often  accom- 
panies movements  of  the  bowels  at  this  time,  is  also  believed  to  cause 
increased  choreic  movements.  Pressure  on  the  uterus  and  the  abdomen 
sometimes  increases  choreic  movements  during  the  puerperal  state.  In  some 
patients  the  nursing  of  infants  has  aggravated  chorea,  the  convulsions 
becoming  so  violent  that  the  nipple  was  jerked  out  of  the  child's  mouth. 

In  choreic  cases  endocarditis  is  sometimes  observed  as  a  complication ;  it 
renders  the  prognosis  much  more  grave.  Hemic  murmurs  dependent  upon 
anemia  are  exceedingly  common  in  these  patients.  An  examination  of  the 
urine  shows  an  excess  of  urea  and  phosphates,  probably  the  result  of  the 
increased  muscular  activity  of  the  convulsive  seizures.  The  chief  difficulty 
in  diagnosis  arises  in  differentiating  the  true  chorea  of  pregnancy  from  the 
hysterical  and  mixed  forms.  Attention  may  again  be  called  to  the  fact  that 
in  true  chorea  movements  are  irregular  and  spasmodic,  and  are  increased  by 
motion  and  voluntary  effort,  especially  if  such  effort  is  sustained.  In  the 
hysterical  form  movements  are  sudden,  isolated,  and  often  rhythmical,  espe- 
cially in  the  fingers.  Hysterical  chorea  never  becomes  so  intense  as  greatly 
to  exhaust  the  patient.  Delirium,  acute  mania,  and  delusions  may  compli- 
oate  chorea  during  pregnancy,  as  illustrated  in  the  cases  described  by  Jones  :268 
one  of  his  cases  was  complicated  by  septic  infection  following  premature 
birth  of  a  decomposed  fetus  at  seven  months.  In  another  ca-e  paralysis  of 
the  left  arm  occurred  as  a  complication.  Children  born  of  choreic  mothers 
sometimes  show  marked  tendency  to  convulsive  movements.  Bue 269  describes 
2  cases  in  which  the  chorea  of  the  mother  was  manifested  in  convulsive  move- 
ments of  the  child.     Maniacal  chorea  is  to  be  distinguished  from  the  mania 


THE  PATHOLOGY   OF  PREGNANCY.  255 

of  pregnancy  and  the  puerperal  state  by  a  previous  history  of  choreiform 
movements.  In  default  of  such  history  an  exact  diagnosis  is  often  difficult. 
In  maniacal  chorea  the  patieuts  are  less  sullen  and  are  more  garrulous  than 
in  true  mania.  In  estimating  the  dangers  of  chorea  in  pregnancy  the  violence 
of  choreic  movements,  the  amount  of  sleep  lost  in  consequence,  and  the 
intercurrent  complications  must  all  be  considered.  The  prognosis  of  mani- 
acal chorea  is  usually  favorable  as  regards  the  mental  condition.  Occasion- 
ally mental  defect  persists  for  a  long  time  after  labor,  and  it  may  ultimately 
become  permanent.  Septicemia  and  pyemia  very  seriously  complicate  such 
cases. 

So  far  as  treatment  is  concerned,  sedatives  and  narcotics  have  been  used 
extensively,  with  but  indifferent  success.  The  indications  for  treatment  are 
to  secure  bodily  and  mental  rest  and  sleep,  and  to  bring  about  an  improved 
condition  of  the  patient's  blood  and  nutrition.  It  is  often  necessary  to  pro- 
tect the  patient's  skin  from  friction  caused  by  the  severity  of  the  movements. 
A  profoundly  depressed  mind  and  nervous  system  call  for  an  entire  change 
of  surroundings.  In  the  medication  of  these  cases  arsenic,  suitable  diet,  and 
the  maintenance  of  proper  digestion  are  of  the  greatest  importance.  Rest 
in  bed,  freedom  from  annoyance  and  excitement,  bathing,  and  gentle  fric- 
tion are  also  of  value.  To  procure  sleep,  chloral  in  doses  of  from  30  to  40 
grains  has  given  good  results.  Gairdner270  relates  the  case  of  a  girl,  eight 
years  of  age,  who  by  mistake  took  60  instead  of  20  grains  of  chloral  to  pro- 
cure sleep  ;  she  recovered  from  the  effects  of  the  drug,  and  was  permanently 
cured  of  chorea  by  the  dose  she  had  taken.  In  these  cases  Trousseau  and 
Gowers  have  used  strychnin  pushed  to  a  physiological  effect.  Sodium  sali- 
cylate, wet  packs,  and  the  application  of  cold  to  the  spine  have  also  been 
recommended.  So  far  as  the  obstetrical  treatment  of  these  cases  is  concerned, 
the  obstetrician  must  guard  against  hemorrhage,  to  which  the  anemia  so  gen- 
erally present  predisposes.  Violent  choreic  movements  also  render  it  diffi- 
cult to  control  the  uterus  during  the  third  stage  of  labor.  The  debilitated 
condition  of  the  patients  exposes  them  to  additional  risk  of  septic  infection. 

When  chorea  persists  after  delivery,  the  mother  should  be  prohibited  from 
nursing,  as  this  undoubtedly  tends  to  aggravate  the  condition.  If  the  chorea 
be  mild  or  of  the  hysterical  variety,  the  pregnancy  should  not  be  interrupted. 
In  all  severe  cases,  however,  labor  should  be  induced.  The  interruption  of 
pregnancy  in  a  choreic  patient  is  strongly  indicated  in  the  following  con- 
ditions :  In  threatened  exhaustion  on  the  part  of  the  mother  from  the  inten- 
sity of  the  movements  and  a  deficiency  of  sleep ;  when  mania  or  fixed  and 
dangerous  delusions  are  present ;  when  a  grave  physical  complication,  such 
as  endocarditis,  increases  the  gravity  of  the  case. 

Pantzer271  reports  the  case  of  a  woman,  aged  twenty-six  years,  pregnant 
for  the  fifth  time,  and  suffering  severely  from  chorea.  In  a  previous  preg- 
nancy her  movements  had  been  so  excessive  that  labor  was  induced,  after 
which  choreic  movements  persisted  for  several  weeks.  During  this  preg- 
nancy she  was  obliged  to  enter  a  hospital.     Although  easily  excited,  the 


256  AMERICAN    TEXT-BOOK   OF    OBSTETRICS. 

disturbance  was  readily  controlled  by  morphin,  and  no  grave  condition 
threatening  the  child  or  herself  was  found  at  parturition.  The  usual  treat- 
ment for  chorea  was  instituted,  with  the  added  precaution  of  avoiding  large 
doses  of  brornidj  which  tend  to  favor  hemorrhage  after  labor.  The  patient's 
labor  was  normal,  and  she  made  a  good  recovery. 

Dakin  272  reports  7  cases  of  pregnancy  complicated  by  chorea,  of  which  2 
died.  The  first  was  a  woman  in  her  second  pregnancy,  who  became  maniacal, 
delirious,  and  exhibited  a  temperature  of  105°  F.  Although  labor  was- 
induced,  the  patient  died  before  it  could  terminate.  At  the  time  of  death 
her  temperature  rose  to  110°  F.  Autopsy  showed  cloudy  swelling  of  the 
heart  muscle,  vegetations  on  the  mitral  valve,  and  cloudy  swelling  of  the 
other  organs.  The  second  fatal  case  was  four  and  a  half  months  pregnant, 
was  delirious,  with  almost  incessant  movements,  and  although  she  improved 
under  treatment  at  first,  her  temperature  rose,  and  she  died  before  the  uterus 
could  be  emptied.  The  other  5  patients  recovered  with  the  induction  of 
labor.  Hyoscin  was  successful  with  some  of  these  patients  with  whom  mor- 
phin did  not  agree.     The  convalescence  was  tedious  in  each  case. 

These  cases  show  that  chorea  is  most  frequent  in  young  primiparse.  It 
usually  appears  during  the  first  six  months,  the  worst  cases  occurring  at  the 
second,  third,  and  fifth  months.  A  mitral  murmur  was  present  in  Dakin's 
cases.  Choreic  movements  cease  when  labor  is  induced.  Grave  symptoms 
are  high  fever,  mania,  and  the  patient's  inability  to  sleep  at  night.  Labor 
must  be  induced  under  an  anesthetic.  In  severe  cases  the  temperature 
should  be  taken  every  hour,  as  it  may  rise  suddenly  and  to  a  dangerous 
extent.     A  temperature  above  100°  F.  should  be  reduced  as  soon  as  possible. 

Catalepsy  is  occasionally  observed  during  the  pregnant  state,  as  in  a  case 
recently  reported  by  Shoot,  of  Lunwarden.273  The  patient  was  a  robust 
woman,  aged  forty-four,  who,  had  borne  eleven  children  ;  in  youth  she  had 
suffei'ed  from  typhus,  and  after  recovery  became  subject  to  fainting  fits,  but 
throughout  her  married  life  she  remained  strong  and  well.  There  was  no 
history  of  a  neurosis  in  her  family.  During  the  seventh  month  of  her 
twelfth  pregnancy  she  was  seized  with  cataleptic  fits  following  the  loss  of  a 
child  ;  she  was  found  stiff  and  motionless  by  the  attending  physician.  The 
forearm  could  be  raised  and  bent  with  some  force,  and  remained  in  the  same 
position  for  about  ten  minutes,  after  which  it  slowly  fell.  The  lower  extremi- 
ties acted  in  a  similar  manner.  Consciousness  was  lost.  The  pulse-beats 
numbered  64,  were  full  and  regular,  and  the  temperature  and  respiration 
were  normal.  The  pupils  were  somewhat  dilated,  but  reacted  to  light.  On 
giving  inhalations  of  chloroform  the  rigidity  of  the  muscles  disappeared,  and 
the  patient  seemed  to  sleep  calmly  for  hours.  On  awakening  she  remem- 
bered nothing  that  had  transpired.  The  fetal  heart-sounds,  previously 
audible,  were  lost,  and  were  not  heard  until  fourteen  days  before  labor.  No 
albumin  was  found  in  the  urine  upon  examination.  Cataleptic  fits  occurred 
three  or  four  times  daily,  occasionally  with  an  interval  of  several  days. 
Atropin  overcame  the  attacks  for  a  week,  but  the  disorder  continued  to  term,. 


THE  PATHOLOGY   OF  PREGNANCY.  257 

when  she  was  safely  delivered  of  an  apparently  healthy  boy.  On  the  fifth 
day  after  labor  an  attack  recurred  while  the  patient  was  nursing  her  child  ; 
two  days  later  the  second  took  place,  which  was  the  last.  Shortly  after  the 
first  attack  her  child,  which  had  been  weaned  because  of  the  cataleptic  com- 
plication, was  seized  with  dysphagia.  During  the  evening  of  the  same  day 
the  child  had  a  cataleptic  fit,  the  symptoms  being  precisely  those  of  the 
mother.  The  rigidity  that  developed  relaxed  during  a  warm  bath,  but  soon 
returned.  Tonic  cataleptic  convulsions  recurred,  and  the  child  died  after 
two  days'  duration  of  the  cataleptic  fits. 

Pregnant  patients  are  exposed  to  those  poisonings  of  the  nervous  sys- 
tem from  lead,  arsenic,  dye-stuffs,  tobacco,  and  other  substances  used  in  the 
arts,  and  that  commonly  act  by  producing,  among  other  complications,  multi- 
ple neuritis.  In  the  absence  of  specific  poisons  multiple  neuritis  is  occa- 
sionally observed,  as  described  by  Solowieff.274  His  patient  was  three  months 
advanced  in  pregnancy  and  suffering  from  nausea  and  vomiting.  No  cause 
for  the  complication  could  be  found  in  the  condition  of  the  urine  or  the 
genital  tract.  Her  nervous  symptoms,  however,  were  peculiar  and  pointed 
to  multiple  neuritis,  especially  well  marked  in  the  lower  extremities  and 
upon  the  back  and  neck.  The  organs  of  special  senses  were  in  a  very  hyper- 
esthetic  condition  ;  the  blood  Mas  normal.  Her  history  included  an  attack 
of  scarlatina  in  childhood  and  also  hysteria.  She  was  nourished  by  rectal 
injections,  and  was  treated  by  faradization  and  hypnotism.  A  careful  study 
of  her  nervous  system  showed  polyneuritis  in  very  wide-spread  degree. 
A  postmortem  examination  showed  all  the  viscera  to  be  free  from  marked 
pathological  change.  The  nerve-trunks,  however,  throughout  the  entire 
body  gave  evidence  of  varying  degrees  of  degeneration ;  this  was  especially 
true  of  the  phrenic  nerves ;  it  had  been  noticed  during  life  that  the  action 
of  the  patient's  diaphragm  was  at  times  very  deficient. 

Diabetes. — Among  the  rare  disorders  of  pregnancy  in  which  the  nervous 
system  and  the  assimilation  of  the  patient  seem  equally  affected  may  be  con- 
sidered diabetes.  Its  rarity  may  be  inferred  from  the  statement  of  Gries- 
singer,  who,  of  53  cases  among  women,  found  but  2  during  pregnancy.  In 
Frerichs'  large  experience,  in  386  cases  there  were  104  among  women  and  but 
1  of  these  had  diabetes  during  pregnancy.  Matthews  Duncan275  reports  the 
case  of  a  multigravida  in  whom  diabetes  was  suspected  for  a  short  time  in 
a  former  pregnancy.  At  the  eighth  month  her  fetus  perished  in  utero.  An 
excessive  amount  of  amniotic  fluid  was  found  to  be  present.  The  patient 
collapsed  before  labor  began,  and  perished  shortly  after.  During  her  first 
pregnancy  she  had  suffered  from  great  thirst,  and  passed  enormous  quantities 
of  urine  during  the  first  few  days  after  delivery.  During  the  pregnancy  that 
ended  fatally  her  urine  was  examined  two  months  before  confinement  and 
nothing  abnormal  was  detected.  It  was  excessive  in  quantity.  The  pa- 
tient's tongue  was  dry  and  brown,  her  breath  had  a  peculiar  sweetish 
odor,  and  purplish  areas  were  detected  upon  the  skin.  Her  temperature  was 
normal,   but   she    suffered    greatly    from   a   sensation   of  oppression.     Reid 

17 


258  AMERICAN    TEXT- BO  OK    OF    OBSTETRICS. 

reports  a  case  similar  to  Duncan's.  The  amniotic  liquid  was  very  abundant, 
and  it  possessed  an  abnormally  large  amount  of  albumin.  The  child  was 
large  and  well  developed,  but  had  died  before  labor  set  in.  Newman  saw 
diabetes  in  two  pregnancies  in  the  same  patient,  the  mother  finally  perishing 
of  the  disease.  Lecorchi  observed  diabetes  in  an  infant  born  of  a  diabetic 
mother.  Williams  reports  a  case,  with  autopsy,  in  which  the  liver  and  kid- 
neys were  found  granular  and  in  pale,  cloudy  swelling.  In  Husband's  case 
the  liquor  amnii  was  saccharine.  Benewitz  and  Winckel  also  report  cases. 
In  Duncan's  case  an  examination  of  the  eyes  revealed  a  large,  pear-shaped 
clot  in  the  central  spot  of  the  retina.  The  patient  was  suddenly  taken  with 
intense  pain  in  the  right  side  of  the  abdomen  in  the  fifth  month  of  preg- 
nancy. Labor  was  induced,  but  the  child  was  dead  and  decomposed.  The 
patient  died,  and  no  cause  for  the  fatal  issue  could  be  found  on  postmortem 
examination.  Frerichs  discovered  in  a  patient,  in  the  eighth  month  of 
pregnancy,  who  suffered  from  diabetes  and  who  perished  after  delivery,  a 
tumor  of  the  medulla  oblongata.  Diabetes  may  occur  during  pregnancy 
only,  being  absent  at  other  times.  It  may  cease  with  the  termination  of 
pregnancy  and  may  recur  afterward.  The  prognosis  for  subsequent  preg- 
nancies is  not  invariably  bad,  as  a  patient,  if  cured  of  diabetes,  may  escape 
in  subsequent  pregnancies.  The  existence  of  diabetes  does  not  militate 
against  conception. 

A  possible  explanation  of  the  occurrence  of  diabetes  during  pregnancy  is 
found  in  the  results  of  the  study  made  by  Oddi  and  Yicarelli ;  m  these 
observers  found  that  during  pregnancy  there  is  a  largely  increased  consump- 
tion of  hydrocarbons  derived  from  the  waste  of  nitrogenous  material  resulting 
from  fetal  nutrition  and  growth.  This  was  seen  by  analyzing  the  air  respired 
by  pregnant  patients.  It  is  rational  to  conclude  that  cases  in  which  this 
metabolism  is  seriously  disturbed  may  furnish  the  complication  of  diabetes 
during  pregnancy. 

Diabetes  seems  to  be  almost  uniformly  fatal  to  the  fetus,  and  that  at  a 
comparatively  early  period  of  gestation.  The  amnion  seems  to  be  the  seat 
of  the  diabetic  process,  and  dropsy  of  the  amnion  or. the  formation  of  sac- 
charine matter  in  the  amniotic  liquid  is  the  condition  most  commonly  observed. 
Fry277  reports  the  case  of  a  patient  in  her  second  pregnancy  who  suffered 
from  great  thirst  and  who  was  easily  fatigued.  Examination  of  the  urine 
showed  9  per  cent,  of  sugar,  which  -\vas  reduced  by  treatment  to  5  per  cent. 
The  child  perished  in  utero  and  the  mother  died  five  days  after  delivery. 

The  treatment  of  diabetes  complicating  pregnancy  is  that  which  the  prac-* 
tice  of  medicine  enjoins  in  such  cases.  The  fact  that  the  life  of  the  fetus  is 
usually  lost  should  lead  the  obstetrician  to  disregard  it  and  to  empty  the 
uterus  promptly  if  the  diabetic  condition  is  pronounced.  Should  the  mother 
survive  labor  or  abortion,  the  prognosis  is,  nevertheless,  unfavorable,  as  the 
diabetic  condition  commonly  persists  and  ultimately  proves  fatal.  The  fact 
that  diabetes  occurs  in  pregnancy  and  that  it  is  attended  with  peculiar  fatality 
emphasizes  the  necessity  for  the  examination  of  the  urine  in  pregnant  patients. 


THE  PATHOLOGY   OF  PREGNANCY.  259 

The  presence  of  more  than  a  trace  of  sugar  should  lead  to  a  thorough  exami- 
nation of  the  patient's  processes  of  assimilation,  when  it  may  be  possible  to 
check  the  further  development  of  diabetes  and  thus  save  the  life  of  both 
mother  and  child. 

The  pathology  of  diabetes  mellitus  complicating  pregnancy  is  well  illus- 
trated by  a  case  reported  by  Hehir.278  The  patient,  a  multigravida,  suffered 
from  diabetes  during  pregnancy,  and  gave  birth  to  a  dead  fetus  nearly  at 
term.  Amniotic  liquid  was  very  abundant  and  turbid,  having  a  heavy, 
mawkish  odor.  An  infusion  was  made  from  the  epidermis  of  the  fetus,  and 
traces  of  sugar  were  found  in  this  infusion.  The  liquor  amnii  was  also 
examined  and  sugar  found.  The  patient  had  been  greatly  annoyed  during 
pregnancy  by  excessive  corpulence,  and  had  suffered  from  polyuria  and 
diabetes  mellitus.  Hehir  also  describes  a  case  of  diabetes  in  pregnancy  in 
which  abortion  occurred  at  the  fifth  month  ;  similar  phenomena  Avere  observed 
in  this  case. 

Idiopathic  universal  pruritus  as  a  complication  of  pregnancy  may  occa- 
sion great  distress  and  may  seriously  interfere  with  a  patient's  rest  and  nutri- 
tion. In  2  cases  reported  by  Feinberg279  exacerbations  of  the  disorder 
occurred  at  the  time  when  menstruation  would  have  appeared  had  not  preg- 
nancy been  present.  Palliative  treatment  mitigated  the  patient's  sufferings 
to  some  extent,  but  it  was  unsuccessful  in  relieving  the  disorder.  Both 
patients  were  exceedingly  nervous,  easily  excited,  and  one  of  them  aborted 
under  great  excitement. 

Pruritus  limited  to  the  vulva  and  vagina  is  frequently  observed  as  a 
complication  in  patients  suffering  from  diabetes  during  pregnancy.  In  such 
cases  any  form  of  treatment  that  lessens  the  quantity  of  sugar  in  the  urine 
decreases  the  patient's  suffering  from  pruritus.  In  cases  not  associated  with 
diabetes  local  applications,  such  as  antiseptics,  in  strong  solution,  painted 
over  the  part,  are  indicated.  Thus,  bichlorid  of  mercury,  1  :  1000,  followed 
by  an  application  of  salt  solution  or  plain  water,  carbolic  acid,  3  to  5  per 
cent.,  tincture  of  iodin,  glycerin,  and  carbolic  acid  are  often  employed.  In 
patients  not  unduly  susceptible  cocain  is  used  to  advantage,  although  the 
extensive  area  to  which  the  application  must  be  made  renders  it  dangerous 
to  patients  readily  influenced  by  the  drug.  The  application  of  electricity  by 
placing  a  moist  electrode  upon  the  mucous  membrane  of  the  vulva  has  been 
beneficial  in  some  cases.  The  observance  of  cleanliness  is  of  great  impor- 
tance, especially  when  a  vaginal  discharge  annoys  the  pregnant  patient. 
Douches  of  carbolic  acid  solution,  of  creolin  and  green  soap,  of  lysol,  of  boric 
acid,  of  alum  in  solution,  or  of  a  hot  solution  of  sodium  bicarbonate  should 
be  tried  faithfully.  Sitz-baths  of  a  warm  solution  of  boric  acid,  of  sodium 
bicarbonate,  or  bran  sitz-baths  are  also  indicated.  The  local  application  of 
starch  and  laudanum  or  lead-water  and  laudanum  is  another  useful  resource. 
When  extensive  irritation  and  excoriation  are  present,  the  application  of  an 
ointment  containing  belladonna,  opium,  and  iodoform  is  often  a  source  of 
great  comfort.     Penciling  the  mucous  membrane  with  silver  nitrate  is  occa- 


260  AMERICAN    TEXT-BOOK   OF    OBSTETRICS. 

sionally  of  value.  Iu  the  majority  of  cases,  however,  the  best  treatment  for 
pruritus  of  the  vulva  and  the  vagina  complicating  pregnancy  is  to  be  found 
in  careful  cleansing,  which  may  be  effected  by  gentle  irrigation  of  the  parts 
with  non-irritating,  antiseptic  fluids,  and  by  constitutional  treatment  directed 
to  improving  the  condition  of  the  patient's  nervous  system  and  the  powers 
of  assimilation. 

Hysteria  daring  pregnancy  furnishes  an  interesting  illustration  of  the  fact 
that  the  pregnant  condition  exaggerates  any  previous  defect  or  susceptible 
point  in  the  patient's  mental  and  physical  organization.  The  belief,  once 
entertained,  that  pregnancy  exercises  a  favorable  influence  upon  women 
already  hysterical  is  certainly  erroneous.  It  occasionally  happens  that  a 
greatly  desired  pregnancy  and  one  occurring  amid  the  most  favorable  circum- 
stances furnishes  a  healthy  stimulus  and  assists  a  patient  in  cultivating  self- 
control,  but  such  cases  are  the  exception  and  not  the  rule.  Mild  forms  of 
hysteria  during  pregnancy  often  take  the  shape  of  melancholia  and  fear  of 
approaching  confinement.  Such  cases  require  patient  encouragement  on  the 
part  of  friends  and  physician,  and  should  stimulate  the  obstetrician  to  take 
every  precaution  that  he  be  not  surprised  by  an  unforeseen  complication 
during  the  labor.  If  the  physician  makes  a  thorough  study  of  his  patient 
before  labor,  and  demonstrates  to  her  that  he  has  taken  every  precaution  in 
her  behalf,  it  will  go  far  toward  allaying  her  apprehensions.  In  the  expe- 
rience of  the  writer  preliminary  examination  of  pregnant  patients  by  palpa- 
tion, auscultation,  and  pelvimetry  often  exercises  a  very  favorable  influence 
in  such  cases.  Hysteria  complicating  pregnancy  becomes  dangerous  when 
it  passes  into  a  condition  of  maniacal  excitement.  Although  the  prognosis 
in  such  cases  is  not  unfavorable  so  far  as  the  recovery  of  the  mother  is 
concerned,  yet  these  -  patients  require  prolonged  and  careful  treatment; 
should  labor  occur  during  mania,  injury  to  the  fetus  or  to  the  mother  may 
result.  Such  cases  require  constant  watchfulness,  kind  and  systematic 
restraint,  and,  when  any  obstetrical  manipulation  is  required,  the  use  of 
anesthetics  is  usually  a  necessity.  One  of  the  dangers  that  threaten  in  these 
cases  is  exhaustion  through  a  refusal  to  take  food  ;  therefore  the  feeding  of 
such  patients  is  a  cardinal  point  in  their  treatment.  As  in  dealing  with  the 
insane,  so  in  these  cases,  it  is  better  to  avoid  deceit  in  their  management,  and 
to  win  the  patient's  confidence  by  faithful  and  patient  attention  without  dis- 
simulation. 

Mania  complicating  pregnancy  is  of  importance  chiefly  as  influencing  the 
course  of  labor  and  the  puerperal  state.  It  is  observed  during  pregnancy  in 
patients  of  very  neurotic  organization,  in  those  having  a  heredity  of  insanity, 
in  women  who  have  been  alcoholic,  hysterical,  or  in  other  ways  neurotic,  and 
in  those  who  suffer  some  great  mental  shock  while  in  the  pregnant  condition. 
Unhappy  marriages  form  a  considerable  element  in  the  causation  of  mania 
during  pregnancy.  The  diagnosis  of  these  cases  is  to  be  made  by  eliminating 
hysteria,  delirium  tremens,  hystero-epilepsy,  and  the  temporary  delusions 
and  hallucinations  that  sometimes  accompany  toxemia  from  deficient  excre- 


THE   PATHOLOGY   OF  PREGNANCY.  261 

tion.  In  the  first,  observation  will  usually  render  the  differential  diagnosis 
easy.  In  cases  of  toxemia  a  study  of  the  patient's  excretions  is  required  to 
arrive  at  a  correct  result.  The  prognosis  in  these  cases  depends  upon  the 
underlying  condition  that  is  the  cause  of  the  mania.  In  those  of  highly 
neurotic  organization,  but  whose  physical  condition  is  good,  the  prognosis  for 
life  is  favorable,  but  the  outlook  for  mental  soundness  is  not  bright.  In 
cases  in  which  mania  has  followed  a  profound  shock,  as  from  sudden  bereave- 
ment, an  accident,  or  calamity,  if  the  patient's  physical  condition  is  good,  the 
prognosis  for  a  complete  recovery  is  also  good  ;  this  is  especially  true  if  the 
child  is  carried  to  term  and  survives  its  birth.  If,  however,  mania  is  grafted 
upon  a  background  of  serious  physical  disability,  where  some  well-marked 
pathological  condition  is  present,  it  may  be  the  forerunner  of  a  fatal  issue, 
if  not  at  labor,  then  within  a  short  time  afterward.  This  is  especially  true 
in  those  cases  in  which  toxemia  and  interstitial  nephritis  are  beginning  and 
in  which  the  patient,  if  she  escapes  eclampsia,  passes  into  a  condition  of 
pronounced  and  fatal  nephritis  after  labor. 

The  treatment  of  mania  during  pregnancy  varies  with  the  condition  that 
excites  the  mania.  What  has  been  said  in  reference  to  the  treatment  of  hys- 
terical mania  applies  to  cases  in  which  the  patient  is  neurotic,  but  is  physi- 
cally in  good  condition.  In  women  who  become  maniacal  in  the  presence  of 
calamities  or  of  sudden  bereavement  the  free  use  of  narcotics  for  a  time,  to 
secure  sleep,  is  often  indicated.  If  the  child  continues  to  live,  the  hope  of 
its  birth  and  maternal  affection  should  be  dwelt  upon  and  used  as  powerful 
mental  tonics  in  dealing  with  the  mother.  Perfect  seclusion  and  protection 
from  all  intrusion  are  absolutely  essential.  When  the  first  shock  to  the 
mind  and  the  nervous  system  has  passed,  all  the  resources  of  the  therapeutic 
art  are  required  to  promote  the  nutrition  of  the  brain  and  nervous  system. 
The  treatment  of  mania  complicated  by  toxemia  through  deficient  excretion 
calls  for  the  avoidance  of  narcotics  and  sedatives  and  the  prompt  securing 
of  active  elimination.  As  soon  as  the  patient  is  freed  from  the  poisons  that 
are  irritating  the  brain,  her  condition  is  usually  markedly  improved. 

Nausea  and  Vomiting  of  Pregnancy. — On  the  border-line  between  the 
physiology  and  the  pathology  of  pregnancy  nausea  and  vomiting  have  been 
considered  by  some  as  an  inevitable  result  from  the  irritation  occasioned  by 
the  development  of  the  pregnant  uterus,  and  by  others  as  a  purely  patho- 
logical phenomenon.  Like  the  kidney  of  pregnancy,  the  pregnant  uterus 
and  its  nerve  supply  are  in  a  condition  of  plethora  that  borders  upon  an 
actual  pathological  change.  The  progress  of  our  knowledge  of  the  pathology 
of  pregnancy  gives  good  reason  at  present  for  the  belief  that  nausea  and 
vomiting  are  not  physiological  but  pathological  accompaniments  of  the 
pregnant  condition.  As  many  patients  pass  through  pregnancy  with  no 
pathological  lesion  of  the  kidneys,  so  many  women  bear  children  without 
the  nervous  irritation  and  the  anemia,  slight  or  profound,  that  accompany 
nausea  and  vomiting. 

The  predisposing  causes  for  the  emesis  of  pregnancy  are  to  be  found  in  a 


262  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

congenital  irritability  of  the  nervous  system,  which  produces  exaggerated 
response  to  normal  reflex  stimuli.  The  predisposing  causes  for  this  affec- 
tion are  anatomical  lesions  in  the  generative  tract,  notably  congenital  mal- 
formation or  dislocation  of  the  pregnant  uterus.  The  exciting  causes  for  this 
complication  are  sudden  shocks  to  the  nervous  system,  which  powerfully 
exaggerate  its  reflex  susceptibility.  An  infective  process  producing  hyper- 
emia and  irritability  of  the  cerebrospinal  axis  may  also  be  an  exciting  cause 
for  the  nausea  and  vomiting  of  pregnancy.  A  pathological  process  that 
affects  the  constitution  of  the  blood  is  also  a  frequent  exciting  cause  in  these 
cases.  Direct  mechanical  injury  or  violence  to  the  pregnant  uterus  often 
begins  and  maintains  this  condition ;  thus,  a  patient  in  early  pregnancy, 
while  straining  or  lifting,  suddenly  retroverts  the  uterus  and  obstinate  emesis 
follows.  Metallic  and  irritant  poisons  absorbed  into  the  system,  vitiating 
the  blood  and  irritating  the  nervous  centers,  produce  nausea  and  vomiting. 
Among  the  most  frequent  of  the  exciting  causes  are  the  movements  of  the 
fetus  in  utero  and  excessive  peristalsis  in  the  mother's  intestine.  Distention 
of  the  bladder  and  the  rectum  is  frequently  present  in  these  cases. 

The  diagnosis  of  this  condition  must  usually  be  made  in  large  part  from 
the  statements  of  the  patient  or  from  those  of  her  attendant.  As  such  vom- 
iting is  most  frequent  in  the  early  morning,  the  physician  rarely  has  an 
opportunity,  except  in  severe  cases,  to  observe  the  phenomenon.  In  mild 
cases  nausea  begins  as  soon  as  the  patient  raises  her  head  from  the  pillow. 
Instant  emesis  ensues,  which  is  usually  accomplished  without  straining  and 
is  often  repeated.  Following  this  emesis  the  patient  may  eat  with  a  relish, 
and  the  phenomenon  may  not  recur  until  the  next  morning.  In  such  cases 
the  matter  vomited  consists  of  mucus,  at  times  of  strongly  acid  reaction,  at 
others  of  neutral  reaction.  In  more  severe  cases  the  sensation  of  nausea 
begins  as  soon  as  the  patient  a,wakes.  When  the  upright  posture  is  assumed, 
vomiting  follows,  which  is  but  little  relieved  by  emesis.  The  material 
ejected  consists  of  mucus,  often  burning  and  bitter  to  the  taste,  and  fre- 
quently exceedingly  sour.  Although  the  patient  may  succeed  in  retaining 
food,  the  sensation  of  nausea  persists  often  until  mid-day  or  even  later ; 
merely  the  sight  or  the  presence  of  certain  articles  of  food  greatly  increases 
the  patient's  distress.  Perturbation  of  any  kind  exaggerates  the  feeling  of 
nausea.  If  vomiting  is  repeated,  it  is  accompanied  by  straining  and  retch- 
ing. After  mid-day  the  patient  improves,  and  may  eat  heartily  at  evening. 
Such  cases  are  accompanied  by  anemia  and  often  by  considerable  loss  of 
weight.  A  third  class  of  cases  is  well  characterized  by  the  term  pernicious; 
in  them  the  sensation  of  nausea  is  present  constantly  during  the  patient's 
waking  hours.  Her  cravings  are  for  varied  articles  of  food  and  drink,  and 
they  are  no  sooner  satisfied  than  a  new  craving  arises.  Vomiting  is  accom- 
panied by  straining  and  retching,  by  dryness  of  the  fauces,  or  by  profuse 
salivation.  The  matter  ejected  is,  first,  mucus  and  the  food  taken,  bile,  and, 
in  severe  cases,  mucus  stained  with  blood  or  with  material  resembling  coffee- 
grounds.     Food  is  no  sooner  swallowed  than  it  is  ejected,  although  there 


THE  PATHOLOGY   OF  PREGNANCY.  263 

occur  occasional  periods  of  tolerance  in  which  the  patient  eats  greedily  and 
that  occasion  hope  in  the  mind  of  the  physician  that  substantial  improve- 
ment has  taken  place.  As  the  case  proceeds  distress  and  pain  are  felt  be- 
neath the  sternum,  not  located  at  any  fixed  point.  The  sensation  is  described 
sometimes  as  smothering,  but  more  often  as  a  distress  that  is  not  concerned 
with  breathing.  In  dangerous  cases  it  is  most  severe  at  night.  Emaciation 
is  progressive — in  some  cases  rapid,  in  other  cases  slow.  A  more  deceptive 
phenomenon  in  these  patients  is  acute  fatty  degeneration  of  the  tissues,  Avhich 
gives  to  the  patient  a  plump  appearance  that  may  deceive  the  physician.  As 
the  case  progresses  the  clinical  picture  of  pternicious  anemia  becomes  more 
and  more  apparent.  Signs  of  disintegration  of  the  blood  are  present  in  the 
vomit,  in  hematogenic  jaundice,  in  sordes,  and  in  purpuric  extravasations. 
The  urine  contains  the  debris  of  broken-down  corpuscles,  the  feces  are  dark 
in  color,  the  mucous  membranes  are  dark  and  reddish  in  appearance,  and  the 
mental  condition  is  one  of  apathy  or  of  delusion,  often  seen  in  these  cases. 
A  further  step  in  the  process  is  observed  in  the  condition  of  the  eyes,  in 
which  a  necrosis  of  the  cornea  and  dimness  of  vision  may  be  noted.  The 
pulse  and  the  cardiac  action  of  the  patient  in  severe  cases  of  nausea  and 
vomiting  of  pregnancy  show  the  effect  upon  the  heart  and  the  arteries  of  the 
gradually  developing  anemia.  The  pulse  is  rapid,  soft,  and  weak.  Arter- 
ial tension  is  usually  diminished,  the  first  sound  of  the  heart  grows  less 
and  less  distinct  and  forcible,  and  in  fatal  cases  cardiac  syncope  develops. 
The  temperatui-e  is  subnormal  at  first ;  later  in  severe  cases  it  increases  as  a 
fatal  issue  approaches.  In  other  cases  the  temperature  varies  slightly  from 
the  normal,  and  in  all  cases  it  is  not  an  important  factor  in  diagnosis  or  in 
prognosis.  The  pulmonary  signs  are  usually  negative  :  the  patient  occa- 
sionally complains  of  an  irritable  cough  that  accompanies  a  dry  condition  of 
the  fauces,  or  sometimes  of  the  accumulation  of  an  excessive  amount  of  mucus. 
Palpation  of  the  abdomen  may  reveal  a  dislocation  of  the  uterus ;  in  the 
early  stages  of  the  more  severe  cases  the  abdominal  walls  are  often  exceed- 
ingly irritable,  the  practice  of  palpation  itself  increasing  the  nausea.  Liver 
dulness  is  usually  slightly  increased  in  area  as  the  liver  becomes  the  seat  of 
acute  parenchymatous  fatty  degeneration.  The  patient's  reflexes  are  much 
increased,  although  paralysis  or  atrophy,  other  than  that  attending  emaciation, 
is  seldom  observed.  The  nutrition  of  the  skin,  except  in  purpuric  cases,  is 
usually  fairly  well  maintained  ;  bed-sores  rarely  occur  in  well-cared-for  cases. 
A  clammy  sweat  is  frequently  seen,  especially  upon  the  face. 

The  symptoms  of  improvement  in  the  condition  of  the  patient  suffering 
from  nausea  and  vomiting  of  pregnancy  are  diminution  in  the  nausea  and 
the  emesis  ;  the  ability  to  take  and  to  retain  food  ;  a  normal  condition  of  the 
excretions,  especially  of  the  urine;  the  absence  or  the  diminution  of  exces- 
sive perspiration ;  considerable  periods  of  sleep  without  emesis,  and  the 
absence  of  the  substernal  distress,  especially  at  night.  The  pulse  falls 
gradually  to  100,  and  the  temperature  remains  normal.  Grave  symptoms 
in  these  cases  are  the  continuance  of  the  nausea  and  vomiting:  and  the  grad- 


264 


AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 


ual  development  of  the  signs  and  symptoms  of  pernicious  anemia.  Among 
the  most  important  of  these  are  a  persistently  rapid,  feeble  pulse,  substernal 
pain  and  distress,  and  coffee-ground  vomit. 

The  pathological  anatomy  of  these  cases  may  be  divided  into,  first,  those 
of  the  organs  of  the  body  other  than  the  generative  organs,  and,  second, 
those  of  the  uterus  and  its  appendages.  In  the  first  class  of  cases  it  is  evi- 
dent that  lesions  that  may  produce  obstinate  nausea  and  vomiting  in  the  non- 
pregnant may  also,  by  coincidence,  be  present  in  gravid  women.  Thus, 
cancer  of  the  stomach  ;  chronic  gastritis,  whether  gouty,  alcoholic,  or  caused 
by  arteriosclerosis  ;  nephritis  in  its  various  forms  ;  brain  tumor ;  chronic 
displacement  of  the  stomach  by  the  pathological  condition  of  adjacent  viscera  ;  ' 
hysteria  producing  emesis  ;  emaciation,  vomiting,  and  acute  yellow  atrophy 
of  the  liver — may  be  present  and  cause  vomiting  in  pregnant  patients.  Of 
these  conditions  but  one  stands  in  a  possible  causal  relationship,  and  is  by 
some  considered  dependent  upon  the  condition  of  pregnancy.  It  has  been 
shown  by  Lomer  and  by  Frerichs  that  this  disorder  may  affect  pregnant 
women  in   forms  of  varying    severity,  and   that  the   milder  cases  of  acute 

yellow  atrophy  of  the  liver,  in  which 
death  does  not  occur  from  this  compli- 
cation, often  reveal  themselves  only 
through  nausea  and  vomiting. 

As  regards  the  changes  to  be  met 
with  in  the  genital  organs  in  these 
cases,  they  are,  first,  those  of  position, 
and,  second,  those  of  structure.  In 
the  former  we  have  acute  and  chronic 
dislocations  of  the  uterus.  Of  these 
dislocations  the  most  common  is  retro- 
version, which  generally  follows  strain- 
ing or  lifting,  and  in  which  the  rela- 
tion between  the  dislocation  and  the 
nausea  and  vomiting  is  that  of  evident 
cause  and  effect.  This  complication  is 
serious  in  proportion  to  the  condition 
of  the  surrounding  parts  :  if  no  adhe- 
sions bind  the  uterus  in  its  abnormal 
position,  the  reduction  of  the  disloca- 
tion is  affected  readily  and  the  exciting 
cause  is  at  once  removed.  When,  how- 
ever, the  pregnant  uterus  becomes  re- 
troverted  and  bound  down  by  adhe- 
sions in  the  process  of  pelvic  inflamma- 
tion, the  pathological  condition  is  far  more  complicated  and  grave.  Chronic 
dislocations  of  the  pregnant  uterus  are  those  in  which  that  organ,  as  a  whole, 
is  forced  downward  in  the  pelvis  and  impacted  with  its  fundus  against  the 


Fig.  U6.— Vomiting  of  pregnancy.    Cyst  in 
anterior  wall  of  cervix  (Davis). 


THE   PATHOLOGY   OF  PREGNANCY. 


265 


symphysis  pubis.  This  condition  of  the  uterus  is  the  result  of  the  persistent 
wearing  of  tight  clothing  before  and  during  the  course  of  pregnancy.  It 
has  been  well  described  and  its  importance  has  been  urged  by  Grailey 
Hewitt  in  a  brochure  entitled  Severe  Vomiting  During  Pregnancy,  pub- 
lished in  London  in  1890.  This  condition  of  impaction  is  not  infre- 
cjuently  accompanied  by  congenital  malformation  of  the  pregnant  uterus, 
evidenced  by  extreme  anteflexion  with  a  pathological  condition  in  the 
cervix  of  great  importance.  It  has  been  repeatedly  observed  in  such 
cases  that  the  cervical  canal  was  tightly  closed  and  that  the  tissues  of  the 
cervix  were  exceedingly  dense  and  resistant.  Davis280  has  recently  called 
attention  to  a  case  of  this  kind  in  which  a  condition  of  excessive  develop- 
ment of  connective  tissue  in  the  cervix,  accompanied  by  the  presence  of  a 
retention  cyst  of  considerable  size  in  the  anterior  wall  of  the  cervix, 
occurred  (Figs.  146,  147). 


Fig.  147.— Vomiting  of  pregnancy.    Dense  connective  tissue  in  cervix  (Davis). 

In  addition  to  these  macroscopical  changes  in  the  uterus  tumors  of  the 
ovary  and  enlai-gement  of  the  tubes  have  been  observed  in  cases  of  nausea 
and  vomiting  of  pregnancy.  In  many  of  these  cases  microscopical  exami- 
nation of  the  endometrium  has  demonstrated  the  presence  of  endometritis 
of  various  forms;  that  this  is  of  itself  a  cause  of  the  nausea  and  vomiting 
has  not  been  demonstrated  ;  the  condition  is  apparently  the  accompaniment 
and  the  result  of  the  congenital  malformations  or  dislocations  previously 
described. 

To  the  researches  of  Lindenmann,  of  Moscow,281  we  owe  the  possession 
of  the  interesting  results  of  microscopical  examinations  upon  the  tissues  of 
a  mother  and  her  fetus  perishing  from  pernicious  vomiting  complicated  by 
polyneuritis.  A  macroscopical  examination  disclosed  enlargement  of  the 
spleen,  with  the  appearance  usual  in  inanition  with  cirrhotic  kidneys  and 
liver.  Microscopical  examination  revealed  neuritis  of  the  phrenic,  pneumo- 
gastric,  median,  and  peroneal  nerves,  it  being  especially  well  marked  in  the 
phrenic.  The  liver  showed  fatty  degeneration  and  cloudy  swelling.  The 
blood-vessels  of  the  spleen  were  dilated,  and  the  blood-corpuscles  could  not 
be  stained  by  coloring  agents.     The  epithelium  of  the  kidneys  showed  fatty 


266  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

degeneration.  The  organs  of  the  fetus  exhibited  fatty  degeneration  of  the 
liver  and  necrosis  of  the  kidney.  The  entire  pathological  picture  was  that 
of  infection  by  a  toxin.  Lindenmann  considers  the  infection  as  an  auto- 
intoxication. In  his  control  experiments  upon  the  case  cited  he  describes 
interesting  observations  on  the  pathology  of  inanition  in  animals,  and  from 
these  comparative  studies  he  excludes  simple  inanition  as  a  cause  for  the 
lesions  in  pernicious  nausea. 

The  rational  treatment  of  the  nausea  and  vomiting  of  pregnancy  is 
impossible  without  a  thorough  knowledge,  first,  of  the  condition  of  the 
patient's  processes  of  assimilation,  and,  second,  of  the  condition  of  the  genital 
tract.  The  patient  must  be  examined  thoroughly  in  order  to  exclude  as  a 
cause  for  the  malady  any  condition  that  has  its  origin  outside  the  genital 
tract,  and  in  order  to  eliminate  the  rarer  complications  of  this  disorder.  A 
thorough  and  painstaking  examination  of  the  uterus,  taking  into  considera- 
tion its  size,  shape,  consistence,  position,  and  the  condition  of  the  pelvic 
tissues  surrounding  it,  is  then  imperative.  In  cases  in  which  the  sensitive- 
ness of  the  patient  is  so  great  that  an  examination  aggravates  the  vomiting, 
anesthesia  by  chloroform  or  ethyl  bromid  is  indicated.  In  making  this 
examination  the  physician  must  differentiate  broadly  between- two  conditions  : 
he  may  find  a  simple  dislocation  of  the  uterus  in  retroversion  or  prolapse  of 
the  uterus,  and  partial  impaction  anteriorly  ;  or  he  may  detect  a  congenital 
malformation  manifested  in  sharp  anteflexion  with  thick  and  resisting  cervix, 
or  a  retroversion  bound  down  by  pelvic  adhesions.  In  the  first  and  simpler 
of  these  conditions  the  uterus  should  be.  restored  to  its  normal  position  ;  this 
almost  invariably  relieves  the  condition.  The  explanation  for  this  relief 
seems  to  be  that  the  constant  irritation  to  the  reflex  nervous  system  that 
pressure  upon  the  pelvic  nerves  maintains  is  relieved  by  replacing  the  uterus  ; 
hence  the  pathological  phenomenon  ceases.  If  retroversion  is  present,  the 
bladder  and  the  rectum  should  be  emptied  thoroughly  and  the  patient  be 
placed  preferably  in  the  Sims  position.  The  perineum  should  be  retracted, 
under  anesthesia  if  necessary,  and  the  cervix  be  drawn  downward  and  back- 
ward with  one  hand,  while  with  the  fingers  of  the  other  hand  the  fundus 
should  be  directed  gently  upward  and  forward.  Reposition  having  thus  been 
effected,  it  is  well  to  retain  the  uterus  in  the  proper  position,  at  first  by  a 
packing  of  antiseptic  gauze,  and  then  by  tampons  of  carded  wool.  If  the 
patient  is  in  the  early  stages  of  pregnancy  and  no  pathological  condition  in 
the  pelvis  is  present,  a  Hodge  pessary  may  be  worn  with  advantage.  In 
prolapse  and  anterior  impaction  of  the  gravid  uterus  it  is  of  great  impor- 
tance that  the  bowel  be  thoroughly  emptied  before  attempting  replacement. 
The  uterus  should  then  be  raised  gently  upon  the  fingers  of  the  physician, 
and  if  difficulty  and  resistance  are  experienced,  an  attempt  at  reposition  with 
the  patient  in  the  knee-chest  posture  should  be  made.  In  these  eases  it  is 
often  observed  that  but  slight  change  in  position  is  sufficient  to  relieve  the 
patient,  and  this  gain,  however  small,  is  to  be  maintained  by  tamponing  the 
vagina   with    soft  antiseptic    material.     If   the   uterus  has  not  assumed  its 


THE  PATHOLOGY   OF  PREGNANCY.  267 

normal  position,  as  soon  as  the  patient's  strength  permits  it  should  again  be 
raised  by  gentle  manipulation  and  the  tampon  be  replaced.  In  this  manner 
it  is  possible,  by  gentle  manipulation  under  thorough  antiseptic  precautions, 
to  restore  very  nearly  to  its  normal  position  a  uterus  prolapsed  and  anteriorly 
impacted. 

In  cases  in  which  the  physician  detects  an  abnormal  condition  of  the 
cervix  the  result  of  congenital  malformation  and  pathological  processes,  the 
case  is  far  more  serious  and  the  treatment  is  more  difficult.  It  is  in  these 
cases  that  dilatation  of  the  cervix,  discovered  by  Copeinan,252  by  a  fortunate 
accident,  to  be  efficient,  is  the  method  of  treatment  to  be  employed.  Cope- 
man's  effort  to  induce  labor  in  a  patient  six  months  pregnant  and  almost 
dead  from  nausea  and  vomiting  is  familiar  to  most  physicians.  Having 
dilated  the  cervix  with  his  fingers  as  much  as  possible,  he  attempted  to  rup- 
ture the  membranes  and  failed.  The  improvement  following  the  dilatation 
was  so  great  that  no  further  interference  was  practised,  and  the  patient 
recovered.  There  can  be  no  cpiestion  but  that  in  cases  in  which  a  patho- 
logical condition  of  the  cervix  is  present  dilatation  is  demanded  without 
delay.  The  physician  should  not  be  misled  by  a  soft  condition  of  the 
external  os,  for  often  a  chronically  congested  mucous  membrane  and  hyper- 
secretion of  the  glands  of  the  cervix  give  to  the  casual  observer  the  impres- 
sion that  the  cervix  is  softened.  Although  this  may  be  true  of  its  external 
portion,  the  internal  os  will  be  found  tightly  contracted  and  its  walls  in  a 
condition  of  dense  resistance.  Dilatation  under  anesthesia,  preferably  by 
chloroform  or  ethyl  bromid,  should  be  practised.  For  this  purpose  the 
finger  is  a  safe  instrument,  but  in  cases  in  which  the  tissue  resists  the  finger 
it  is  necessary  to  use,  first,  steel-bladed  dilators,  as  is  done  by  Wiley  and 
others,  and  then  to  complete  the  dilatation,  to  the  point  of  admitting  the 
finger,  by  solid  metal  bougies.  This  procedure,  of  course,  threatens  the 
normal  termination  of  pregnancy,  and  rupture  of  the  membranes  may  occur 
during  the  dilatation.  The  physician  should  be  prepared  for  this  complica- 
tion by  having  ready  a  suitable  curet  and  douche  tube  with  which  to  curet 
and  douche  the  uterus  thoroughly.  After  the  complete  removal  of  the 
ovum  bv  the  curet  and  douche,  the  uterus  should  be  packed  with  iodoform 
gauze  and  be  carried  well  up  into  the  pelvis.  In  attempting  to  treat  a 
patient  suffering  from  the  nausea  and  vomiting  of  pregnancy,  it  is  incumbent 
on  the  physician  to  make  a  thorough  examination,  and  to  practise  such 
interference  as  his  judgment  may  dictate.  If  he  is  hampered  in  this  exami- 
nation bv  the  prejudices  of  the  patient,  he  must  decide  whether  to  place  the 
responsibilitv  upon  her  and  her  friends  or  to  abandon  the  case. 

In  milder  cases,  where  a  condition  of  simple  irritability  and  hypersecre- 
tion in  the  os  and  cervix  are  detected,  local  applications  to  these  parts  are 
of  great  value.  When  the  mucous  membrane  is  inflamed  and  red,  the 
physician  may,  after  a  cleansing  douche  of  creolin  and  green  soap,  apply 
silver  nitrate  by  pencil  with  advantage.  In  raising  a  dislocated  uterus  in 
the  pelvis,  antiseptic  and  analgesic  ointments  may  be  incorporated  with  the 


268  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

tampons  employed.  Thus  an  ointment  of  belladonna,  iodoform,  and  mor- 
phin  is  sometimes  of  use  in  these  cases.  If  there  is  excessive  secretion, 
iodoform,  belladonna,  and  glycerol  of  tannin  form  a  useful  mixture. 

The  medicinal  treatment  of  the  nausea  and  vomiting  of  pregnancy  consists, 
first,  in  eliminating,  by  examination,  the  need  for  operative  interference,  or 
in  promptly  remedying  a  pathological  condition  of  the  uterus.  A  strict 
control  of  the  patient  is  an  absolute  necessity,  and  here  the  services  of  a 
skilled  and  competent  attendant  are  of  the  greatest  value.  The  patient 
should  be  put  to  bed,  her  strength  conserved  in  every  possible  way,  and  the 
subject  of  nausea  and  vomiting  should  uot  be  dwelt  upon.  She  should 
receive  carefully  prepared  nutriment — if  possible  by  the  mouth — at  regular 
intervals.  If  the  stomach  is  unretentive,  nutritive  enemata  are  demanded, 
as,  for  example,  those  made  from  the  various  preparations  of  beef,  in  the 
form  of  peptonoids,  peptonized  beef,  beef-juice  combined  with  brandy,  with 
milk  peptonized  and  pancreatized.  If  the  use  of  alcohol  is  indicated  and  the 
stomach  cannot  tolerate  dry  champagne  or  brandy  and  soda,  brandy  may  be 
given  by  rectal  injection.  The  list  of  drugs  that  have  been  given  by  the 
mouth  in  these  cases  is  very  great,  and  shows  how  comparatively  unim- 
portant all  have  been  in  radically  relieving  the  disorder.  "When  chronic 
catarrh  of  the  stomach  is  present,  lavage  of  the  stomach  has  been  found  to 
be  of  the  greatest  value.  The  soft-rubber  stomach-tube  should  be  passed, 
and  a  solution  of  sodium  chlorid,  sodium  salicylate,  or  a  dilute  solution  of 
sodium  bicarbonate  should  be  employed.  The  administration  of  animal  fer- 
ments in  connection  with  food  is  also  of  great  value.  Thus  ingluvin,  pan- 
creatin  with  sodium  bicarbonate,  with  mix  vomica,  or  strychnin  and  pepsin, 
are  of  decided  value.  No  attempt  should  be  made  to  give  solid  food  until 
the  patient's  strength  has  been  considerably  increased  and  the  condition  of 
the  tongue  warrants  its  trial.  /  When  solid  food  is  given,  it  is  well  at  times 
to  consult  the  patient's  appetite  and  craving,  if  these  do  not  demand  articles 
of  an  injurious  character.  Scraped  raw-beef  sandwiches,  oysters,  junket, 
milk  with  lime-water  or  with  Vichy,  and  freshly  made  broth  in  which  bread 
is  dipped,  are  usually  of  value. 

In  the  treatment  of  this  complication  drugs  are  useful  only  in  so  far  as 
they  assist  in  preserving  the  patient's  strength.  It  is  folly  to  drug  a  patient 
with  narcotics  while  the  physician  is  ignorant  of  the  position  and  condition 
of  the  pelvic  organs,  and  the  prolonged  administration  of  morphin  is  often 
simply  a  mask  for  negligence  or  incompetence.  It  is  much  wiser  to  procure 
sleep  by  the  administration  of  alcohol  by  the  rectum  at  night,  by  sponging 
with  warm  water  and  bathing  whisky,  and  by  keeping  the  patient  in  perfect 
repose,  than  by  the  administration  of  depressing  remedies.  Of  narcotics, 
when  these  are  indispensable,  morphin  and  atropin  or  codein  are  undoubtedly 
the  best.  In  extreme  cases  prompt  and  vigorous  stimulation  must  be  brought 
into  play  to  tide  the  patient  over  the  collapse  that  may  follow  the  dilatation 
of  the  cervix  or  the  emptying  of  the  uterus.  In  this  case  the  hypodermic 
use  of    strychnin,  digitalis,    atropin,  and   alcohol,  the  transfusion   of   saline 


THE   PATHOLOGY    OF   PREGNANCY. 


269 


solution,  the  application  of  electricity  to  the  spine,  the  application  of  heat  to 
the  base  of  the  brain  and  about  the  trunk  of  the  body,  are  all  of  value. 

Those  cases  in  which  the  spontaneous  cure  of  this  condition  occurs  are 
most  reasonably  explained  by  assuming  the  spontaneous  reduction  of  dislo- 
cations of  the  uterus.  Experience  has  shown  that  it  requires  but  a  slight 
change  in  the  position  of  this  organ  to  alter  a  state  of  irritant  pressure  to 
a  condition  in  which  no  irritation  or  but  little  is  produced.  From  our 
knowledge  of  pathology,  no  other  rational  explanation  for  these  cases  can  be 
given.  The  folly  of  waiting  for  such  a  change  to  occur  without  using  every 
effort  to  place  the  uterus  in  a  proper  position  is  self-evident.  It  is  remarkable 
that  this  most  important  point  in  treatment — namely,  the  securing  of  a 
proper  position  of  the  uterus — should  have  been  considered  as  a  last  resort. 


Fig.  148.— Air-ball  pessary  in  position,  raising  the  uterus. 

That  such  a  change  may  often  be  produced  simply  by  the  posture  of  the  patient 
is  illustrated  in  a  case  reported  by  Grant,283  who,  as  a  last  resort,  elevated  the 
hips  of  a  patient  upon  pillows,  whereupon  the  vomiting  ceased.  The  fact 
that  curetting  the  uterus  in  urgent  cases  is  followed  by  immediate  relief  is 
well  illustrated  by  Roland 2Si  and  Blanc.285  The  excellent  results  following 
the  reduction  of  dislocations  of  the  uterus  find  abundant  illustration  in 
Hewitt's  Reports,  in  which  the  use  of  the  Gariel  air-ball  pessary  is  described 
and  fully  illustrated.  This  instrument  is  of  value  when  the  finger  has  dis- 
lodged the  anteriorly  impacted  uterus,  and  its  use,  under  antiseptic  precau- 
tions, has  been  attended  with  excellent  results.  The  accompanying  illustra- 
tion (Fig.  148)  shows  the  air-ball  pessary  in  position,  raising  the  uterus  in 


270  AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 

the  pelvis.  Kingman  236  also  describes  cases  in  which  the  reduction  of  uterine 
dislocations  has  cured  nausea  and  vomiting. 

Ptyalism  complicating  this  condition  has  been  well  described  by  Ahlfeld,237 
who  believes  that  these  cases  are  primarily  neurotic  in  origin,  and  treats  them 
accordingly.  With  the  same  view  of  the  causation  of  vomiting,  Gunther233 
treats  these  cases  by  galvanism,  the  positive  pole  being  applied  to  the  cervix, 
the  negative  betwean  the  eighth  and  twelfth  dorsal  vertebra?.  From  2J-  to  5 
milliamperes  were  employed  for  from  seven  to  ten  minutes ;  so  long  as  the 
current  was  uninterrupted  no  interference  with  the  progress  of  pregnancy 
was  apparent.  Sanger  and  Hennig  239  describe  cases  in  "which  the  exciting 
cause  of  vomiting  was  a  pathological  condition  in  the  uterus  or  in  some 
abdominal  organ. 

Bacon  29°  contributes  a  paper  upon  the  vomiting  of  pregnancy  in  which  he 
reviews  the  literature  of  the  subject  and  describes  4  cases  coming  under  his 
observation.  His  study  leads  him  to  believe  that  the  abnormal  irritability 
of  the  nervous  system  present  is  best  allayed  by  keeping  the  patient  in  the 
horizontal  position,  by  caring  properly  for  the  skin,  bowels,  and  kidneys, 
and  by  using  rectal  or  hypodermic  injections  of  salt  solution.  The  sources 
of  peripheral  irritation  should  be  discovered  and  treated.  In  extreme  cases 
subcutaneous  saline  injections  are  especially  valuable.  Bacon  believes  that 
the  interruption  of  pregnancy  is  never  justifiable.  Kiihne291  reports  2  cases 
of  the  nausea  of  pregnancy.  In  one  of  these  the  disorder  was  aggravated 
by  the  visit  of  relatives ;  the  patient  refused  to  take  nourishment,  so  that 
it  became  necessary  to  empty  the  uterus.  When  pregnancy  terminated  the 
patient's  condition  was  desperate,  with  high  temperature,  chills,  and  rapid 
pulse.  She  made  a  tedious  recovery.  During  convalescence  she  was  found 
to  be  suffering  from  polyneuritis.  There  was  also  some  impairment  of  the 
mental  condition,  and  the  patient  did  not  regain  vigor.  Solowieif m  and 
Eulenberg  293  report  similar  cases  of  polyneuritis.  Kuhne's  second  case  was 
that  of  a  primipara,  seventeen  years  old,  with  emesis,  icterus,  and  great  rest- 
lessness, followed  by  stupor  and  mental  impairment.  The  patient  died  sud- 
denly without  evident  cause.  At  the  autopsy  no  cause  for  death  was  found. 
This  case  is  apparently  inexplicable,  as  the  patient's  vomiting  had  begun  to 
diminish  and  she  could  take  nourishment  ;  evidently,  death  was  due  to 
failure  of  nervous  energy.     The  patient  had  lost  weight  and  was  verv  restless. 

In  some  patients  an  abnormal  condition  of  excitement  arises  in  various 
portions  of  the  nervous  system.  Schaeffer294  describes  the  case  of  a  patient 
who  had  pruritus,  vaginismus,  ovarian  pain,  and  the  excessive  formation  of 
acid  in  the  stomach,  with  obstinate  vomiting.  Pregnancy  progressed  to  term, 
and  spontaneous  delivery  occurred,  with  but  little  pain  during  labor.  On 
the  eighth  day  of  the  puerperal  period,  after  a  sharp  attack  of  diarrhea,  the 
pain  in  the  ovary  disappeared. 

The  writer  reports  3  cases  of  fatal  nausea  and  vomiting  of  pregnancy.295 
In  the  first,  occurring  in  a  primipara,  illegitimate  pregnancy,  which  had  not 
been  diagnosticated,  was  present.     The  uterus  was  retroverted  ;  the  patient 


THE   PATHOLOGY    OF  PREGNANCY.  271 

had  been  treated  for  chronic  gastritis.  An  autopsy  could  not  be  obtained. 
In  the  third  case  the  patient  was  seen  but  once  in  consultation,  and  died 
subsequently  in  a  sanatorium  in  spite  of  general  medicinal  treatment. 
Davis  'm  reports  a  case  of  ectopic  gestation  in  which  pernicious  nausea  of 
pregnancy  was  the  first  suspicious  symptom.  Rupture  occurred.  The 
patient  was  operated  upon  and  recovered.  In  the  same  paper  Davis  and 
Harris29'  report  the  case  of  a  multipara  who  died  from  pernicious  nausea 
after  the  uterus  had  been  einjitied.  Upon  autopsy  syncytioma  malignum  was 
found  in  the  brain,  liver,  kidneys,  and  luugs.  The  uterus  and  pelvic  organs 
were  normal.  This  case  is  unique  in  the  literature  of  the  nausea  of  preg- 
nancy, and  is  the  second  case  reported  of  syncytioma  malignum  in  which  the 
pelvic  organs  were  found  unaltered. 

In  considering  the  treatment  of  this  condition  recent  writers  upon  the 
subject  call  attention  to  the  great  importance  of  the  general  state  of  the 
patient.  Shaeffer  **  brings  evidence  to  show  that  this  condition  is  the  result 
of  toxemia  acting  upon  the  general  nervous  system.  The  nourishment  of 
the  child  suffers  correspondingly  with  that  of  the  mother,  as  is  shown  by 
Klein.299  The  influence  of  a  local  condition  is  well  illustrated  in  Reynold's 
case.300  In  this  case  a  pelvic  tumor  complicating  the  pregnancy  was  found, 
but  its  exact  nature  could  not  be  determined  by  vaginal  examination.  The 
abdomen  was  opened,  aud  the  uterus  was  found  to  be  about  three  months 
pregnant ;  a  fibroid  tumor  also  was  present.  The  cervix  was  dilated  and  the 
ovum  removed,  after  which  the  patient  made  a  good  recovery.  When  the 
uterus  must  be  emptied,  rapid  dilatation  with  solid  or  branched  steel  dila- 
tors is  unquestionably  the  most  efficient  treatment.  Goffe 301  reports  a  case 
in  which  vomiting  ceased  immediately  after  the  parts  were  thoroughly 
dilated  with  a  steel  dilator.  The  rapid  emptying  of  the  uterus  is  also  urged 
by  Merle.302  He  dilates  the  uterus  with  solid  metal  dilators  and  removes 
the  ovum  with  the  finger. 

The  value  of  raising  the  uterus  in  mild  cases  of  nausea  is  illustrated  by 
MacKinnon.303  His  observations  have  been  repeated  by  many  others.  Tam- 
poning of  the  cervix  was  successful  in  the  hands  of  Kehrer.31"  The  os  and 
cervix  were  packed  tightly  with  strips  of  sterile  gauze  saturated  with  glycerin. 
The  nausea  ceased  immediately,  and  did  not  recur  for  several  days,  when  the 
tampons  were  renewed.  By  this  means  the  patient  was  carried  along  in 
pregnancy  until  the  thirty-third  week,  when  labor  was  induced  and  she  was 
delivered  of  a  living  child,  which  survived. 

The  treatment  of  the  nausea  and  vomiting  of  pregnancy  may  be  summar- 
ized as  follows  :  Recognizing  the  neurotic  element  in  these  cases,  the  patient 
should  be  controlled  by  a  firm  and  cheerful  mental  influence.  She  should  be 
placed  at  absolute  rest,  and  be  fed  well  and  persistently.  Those  drugs  that 
tend  to  soothe  and  stimulate  the  nervous  system  may  be  given  and  may 
be  found  to  be  partially  successful.  The  element  of  toxemia  must  not  be 
neglected,  and  the  employment  of  injections  of  saline  fluid  and  the  abundant 
use  of  water  are  indicated. 


272  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

It  is  of  especial  importance  that  the  condition  of  the  pelvic  organs  be  not 
overlooked.  Tenesmus  of  the  pelvic  muscles,  impaction  of  the  uterus,  mal- 
positions of  the  uterus,  and  altered  conditions  of  the  cervix  must  all  be 
recognized  and  appropriately  treated.  It  is  well  to  raise  the  uterus  above  its 
usual  location  in  the  pelvis.  This  is  done  best  by  packing  with  tampons  of 
aseptic  wool.  Should  these  measures  fail  and  the  patient's  strength  pro- 
gressively diminish,  she  should  be  anesthetized  with  ether  or  with  chloro- 
form and  oxygen,  the  cervix  dilated  with  graduated  or  solid  bougies,  and  the 
uterus  emptied  by  the  finger  or  curet.  The  uterine  canal  should  be  kept 
open  by  means  of  gauze  j^acking  for  several  days. 

Under  antiseptic  precautions  and  with  free  stimulation  the  emptying  of 
the  uterus  by  this  means  does  not  militate  against  the  patient's  recovery  in 
cases  that  are  seen  before  they  reach  a  desperate  condition. 

In  moribund  cases  and  in  those  suffering  from  malignant  disease  all  treat- 
ment is  useless. 

Ascites  complicating  pregnancy  may  arise  from  a  lesion  of  the  abdominal 
viscera  interfering  with  the  return  circulation  and  also  with  the  lymphatic 
circulation  of  the  peritoneum.  Pregnancy  itself  sometimes  gives  rise  to 
ascites  through  a  pathological  condition  that  affects  the  peritoneum  of  the 
mother  and  the  amnion  of  the  fetus  by  a  similar  process.  An  interesting 
case  illustrating  this  condition  is  reported  by  Florentine.303  The  patient  was 
a  young  woman  who  had  been  married  three  years  and  who  had  borne  one 
living  child  and  had  had  one  abortion.  The  cessation  of  menstruation  was 
followed  by  obscure  pain  in  the  abdomen,  increase  in  size,  and  the  evident 
pressure  of  fluid.  Pressure  symptoms  became  so  pronounced  that  suffoca- 
tion was  threatened  and  pains  resembling  those  of  labor  supervened.  The 
membranes  were  ruptured,  when  the  entire  fetus  with  a  large  quantity  of 
amniotic  liquid  was  suddenly  expelled.  Distention  of  the  abdomen  was 
relieved  by  paracentesis.  Ovarian  cyst  was  then  diagnosticated,  and  the  tumor 
was  removed  a  month  later.     Recoveiy  ensued. 

Tubercular  peritonitis  complicating  pregnancy  is  also  a  cause  of  ascites, 
and  it  may  develop  gradually  as  gestation  advances.  The  most  preferable 
treatment  of  abdominal  dropsy  complicating  pregnancy  is  by  exploratory 
incision.  If  a  tubercular  process  is  present,  the  prognosis  for  marked  im- 
provement, if  not  for  recovery,  is  excellent.  If  a  pathological  condition  of 
the  lymphatic  system  of  the  peritoneum  is  the  cause  of  the  condition,  free 
drainage  by  incision  is  the  safest  treatment.  The  immunity  displayed  by 
pregnant  patients  to  operative  procedures  when  properly  conducted  renders 
such  interference  safe  and  highly  appropriate. 

Phantom  pregnancy,  or  pseudocyesis,  may  result  from  a  strong  desire 
for  pregnancy  in  a  patient  suffering  from  ascites.  An  illustrative  case  is 
reported  by  Clay.306  Phantom  pregnancy  without  pathological  lesion  is  not 
a  rare  condition.  In  nervous  patients  who  strongly  desire  pregnancy,  and 
who  are  past  the  time  of  greatest  reproductive  activity,  the  symptoms  of 
pseudocyesis  are  the  subjective  symptoms  of  normal  gestation. 


THE   PATHOLOGY   OF  PREGNANCY.  273 

The  diagnosis  and  treatment  of  this  condition  are  completed  by  a  thorough 
examination,  and  whenever  the  patient  will  submit  to  examination  under 
an  anesthetic,  the  cure  is  usually  complete.  In  such  cases  it  is  well  to  have 
a  friend  of  the  patient  present  at  the  examination,  in  order  to  witness  person- 
ally the  disappearance  of  the  abdominal  tumor  as  anesthesia  proceeds.  Illus- 
trative cases  are  found  in  the  literature  of  the  subject,  and  among  them  is 
that  of  Johnston.307 

Davis303  reports  3  cases  of  pseudocyesis.  The  first  occurred  in  a  gouty 
patient  who  married  comparatively  late  in  life  and  in  whom  examination 
under  ether  proved  the  absence  of  pregnancy  and  dispelled  the  illusion.  His 
second  case  occurred  in  a  girl  of  sixteen,  who  had  been  an  inmate  of  several 
charitable  institutions,  and  gave  a  history  of  criminal  assault  and  pregnancy. 
She  could  enlarge  the  abdomen  at  will  so  that  it  would  simulate  an  eight 
months  gestation.     Examination  under  ether  demonstrated  the  condition. 

His  third  case  occurred  in  a  woman  twice  married.  During  her  first 
marriage  she  had  two  abortions  at  about  seven  months.  Shortly  before  com- 
ing under  observation  she  had  passed  through  a  spurious  labor,  during  which 
a  nurse  and  physician  were  in  attendance  for  some  time.  She  ajyparently  had 
severe  labor  pains  and  had  an  enlarged  abdomen  for  some  time  previously. 
Upon  examination  it  was  found  that  pregnancy  was  absent,  but  that  fat  and 
very  flabby  tissues  were  present ;  close  examination  showed  that  the  patient 
had  myxedema,  from  which  she  had  partially  recovered  under  treatment  by 
thyroid  extract.  She  was  highly  neurotic  and  badly  nourished.  The  coin- 
cidence of  myxedema  and  pseudocyesis  illustrates  the  neurotic  element  in 
these  cases. 

Acute  yellow  atrophy  of  the  liver  in  the  pregnant  woman  is  an  infec- 
tious disease  of  uncertain  origin.  Of  143  cases  of  this  disorder,  Thierfelder 
observed  30  during  pregnancy.  Spaeth  saw  it  but  once  in  16,502  pregnant 
women.  Epidemics  of  this  disorder  have  been  reported  by  Kerksig,  Char- 
pentier,  and  Bardinet.  Lomer's  excellent  paper  upon  the  subject  and  the 
reports  of  Matthews  Duncan  30°  describe  this  complication  fully.  The  symp- 
toms are  those  of  jaundice,  hematogenic  and  hepatogenic,  with  evidence  of 
profound  intoxication  from  the  absorption  of  septic  material  and  toxins. 
On  palpating  the  abdomen  the  area  of  liver  dulness  is  diminished.  After 
the  stage  of  incubation,  lasting  from  three  to  five  days,  the  patient  has  gastric 
and  intestinal  catarrh,  with  rigor,  pains  in  the  head  and  back,  and  fever.  Albu- 
minuria often  is  present.  In  severe  cases  great  tenderness  exists  over  the 
liver  and  abdomen.  Occasionally  the  disease  results  in  death  before  delivery. 
As  a  rule,  patients  die  in  labor  or  following  abortion.  In  a  case  recently 
observed  by  the  writer,  the  pronounced  jaundice  of  the  mother  was  rej>ro- 
duced  in  the  bright  yellow  color  of  the  amniotic  liquid  and  the  deep  orange 
staining  of  the  fetus  and  its  appendages.  This  patient  had  high  fever  before 
delivery  and  died  in  septic  coma  shortly  afterward.  Acute  yellow  atrophy 
with  malignant  jaundice  is  due  to  blood-poisoning  from  acute  septic  infec- 
tion.    The  prognosis  is  exceedingly  grave,  and  the  treatment  of  these  cases 


274  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

consists  in  the  effort  to  terminate  pregnancy  promptly,  to  arouse  the  secre- 
tions of  the  intestinal  canal,  and  to  support  the  patient's  strength. 

The  milder  form  of  jaundice  during  pregnancy  may  result  from  impac- 
tion of  feces,  catarrh  of  the  bile-ducts,  pressure  of  the  pregnant  uterus  upon 
the  liver,  and  the  physiological  hyperemia  that  the  liver  shares  in  common 
with  other  abdominal  viscera.  Failure  in  excretion  by  the  kidneys  in  greater 
or  lesser  degree  is  often  noted  in  these  cases,  and  the  development  of  gall- 
stones is  a  not  infrequent  accompaniment.  When  the  disorder  is  recognized 
promptly  and  the  gastro-intestinal  tract  is  subjected  to  proper  and  efficient 
treatment,  it  is  possible  often  to  avoid  fatal  issue.  Winter 3UI  describes  an 
illustrative  case  in  which  a  multigravida  who  had  suffered  from  malarial 
intoxication  was  attacked  with  jaundice.  After  a  violent  illness  lasting  six 
or  eight  days,  with  severe  gastric  disturbance  and  vomiting,  premature  labor 
occurred,  after  which  the  mother  recovered.  The  treatment  of  this  condi- 
tion is  the  medicinal  treatment  appropriate  for  these  cases  in  the  non-pregnant. 
In  well-marked  cases  premature  labor  is  likely  to  occur,  and  in  protecting 
the  interests  of  the  mother  no  effort  should  be  made  to  avoid  it. 

Gastric  ulcer  complicating  pregnancy  has  been  observed  by  Robert 
Koch311  in  2  patients,  each  of  whom  suffered  from  profuse  hematemesis 
accompanied  by  abdominal  distress.  In  one,  the  milder  case,  pregnancy  was 
interrupted  and  a  living  child  was  born.  In  the  other  the  patient  collapsed 
after  vomiting  blood  freely,  and  although  she  rallied  and  ultimately  recov- 
ered, her  child  was  stillborn. 

Appendicitis  complicating  pregnancy  has  been  well  described  by  Mixter.312 
Premature  labor  followed  the  attack,  and  an  abdominal  tumor  demanded 
operation.  The  appendix  was  found  at  the  lower  end  of  the  kiclnev,  its 
position  having  possibly  been  altered  by  the  pregnant  uterus.  Fecal  concre- 
tions were  present.     Recovery  followed  the  operation. 

Pinard 313  describes  the  case  of  a  woman  who  was  said  to  have  had  general 
peritonitis  following  rupture  of  the  uterus.  The  patient  had  been  delivered 
by  forceps  after  a  somewhat  difficult  and  tedious  labor.  Symptoms  of  gen- 
eral peritonitis  rapidly  developed.  At  the  operation  an  infected  appendix 
containing  a  fecal  calculus  was  found.  The  patient  did  not  recover.  It  is 
not  difficult  to  understand  how  general  peritonitis  occurring  after  a  difficult 
labor  might  be  mistaken  for  abdominal  infection  following  rupture  of  the 
uterus. 

Pinard  reports  3  cases  of  appendicitis  occurring  in  early  pregnancy,  in 
which  abortion  and  the  removal  of  the  appendix  were  followed  by  recovery, 
In  one  of  these  cases  premature  labor  occurred.  He  also  describes  a  case  of 
intestinal  occlusion  in  a  pregnant  woman,  in  whom  abdominal  section  revealed 
inflammation  of  the  appendix  to  be  the  cause.  The  removal  of  the  appendix- 
was  followed  by  recovery.  Appendicitis  occurs  equally  as  often  among  primi- 
parse  as  among  multiparas,  and  at  all  periods  of  gestation.  It  is  often  slow 
and  insidious  in  development,  and  may  be  mistaken  for  infection  resulting 
from  abortion  or  labor.     It  is  to  be  treated  sursjicallv  in  all  cases. 


THE   PATHOLOGY   OF  PREGNANCY.  275 

Abrahams314  has  collected  11  cases  of  appendicitis  reported  by  American 
authors.  He  adds  4  cases  seen  by  himself.  Of  these,  1  was  mild,  occur- 
ring about  the  seventh  month  of  gestation,  and  improved  under  local 
applications  of  ice  and  with  the  administration  of  opium.  The  second 
patient,  a  multipara,  suffered  from  a  catarrhal  appendicitis  during  pregnancy 
for  which  operation  was  unnecessary  and  which  continued  after  the  delivery 
of  the  child.  In  the  third  case  the  patient  was  five  months  pregnant ;  opera- 
tion was  decided  upon,  but  the  temperature  fell  to  normal  and  recovery  fol- 
lowed without  operation.  The  fourth  case  occurred  in  a  pregnant  woman 
who  was  injured  in  the  right  iliac  fossa ;  she  was  delivered  in  spontaneous 
labor.  On  the  fifth  day  intense  pain  developed,  with  rapid,  feeble  pulse  aud 
high  temperature.  Collapse  ensued  and  the  patient  was  revived  with  diffi- 
culty by  stimulation.  She  rallied  gradually  and  made  a  partial  recovery. 
After  convalescence  she  complained  of  constant  pain  in  the  right  iliac  fossa. 

Marx310  reports  a  case  developing  after  labor  and  recovering  without 
operation.  After  convalescence  typical  attacks  occurred,  and  a  diseased 
appendix  was  removed.  In  a  second  case  the  appendix  was  removed 
when  the  patient  was  four  months  pregnant,  and  recovery  followed  without 
the  interruption  of  pregnancy.  When  labor  came  on  the  patient  experienced 
pain  from  adhesions,  and  the  child  was  delivered  with  forceps.  In  the  third 
case,  when  the  patient  was  two  and  a  half  months  pregnant,  a  suppurating 
ovarian  dermoid  cyst  was  removed  through  the  abdominal  wall.  She  had  a 
rapid  labor,  followed  by  the  development  of  appendicitis,  which  rapidly  grew 
worse.  An  abscess  and  an  adherent  appendix  were  found.  The  patient 
made  a  good  recovery.  The  fourth  case  occurred  in  a  woman  seven  months 
pregnant  when  attacked  by  appendicitis  with  vomiting.  Operation  was  per- 
formed, and  the  tube  and  ovary  of  the  affected  side  were  removed  with  the 
appendix.  This  was  followed  by  labor.  The  patient's  convalescence  was 
retarded  through  the  pocketing  of  pus  in  the  abdomen.  Recovery  ulti- 
mately ensued. 

In  the  fifth  case,  in  which  pregnancy  was  four  and  a  half  months 
advanced,  vomiting  occurred.  The  patient  became  very  ill  and  had  a  rapid 
pulse.  Encapsulated  abscess  was  found,  with  a  pus-tract  leading  down  to 
the  vagina.  The  patient  improved,  but  again  became  worse  and  ultimately 
perished  from  septic  absorption  from  several  abscess  cavities. 

McArthur316  reports  a  case  occurring  in  a  woman  four  and  a  half  months 
pregnant,  in  whom  abscess  of  the  appendix  or  ruptured  tubal  abscess  was 
diagnosticated.  At  operation  the  abscess  was  found  to  have  involved  the 
uterus,  and  was  opened  and  drained  without  breaking  adhesions.  The 
appendix  was  gangrenous.  The  abscess  was  drained  by  gauze  packing,  but 
abortion  and  death  followed  from  septic  infection.  Great  sensitiveness  and 
flatness  existed  over  the  region  of  the  appendix.  Labor  occurred,  and  the 
patient  perished  from  exhaustion. 

Appendicitis  in  the  mother  may  result  in  the  conveyance  of  infection  to 
the  umbilical  region  of  the  child.     Pinard 317  reports  the  case  of  a  woman, 


276  AM  ERICA  X    TEXT-BOOK    OF    OBSTETRICS. 

six  months  pregnant,  who  died  of  appendicitis  followed  by  abortion.  On 
making  cultures  from  the  umbilical  cord  the  colon  bacillus  was  discovered. 

Albuminuria  and  peptonuria  are  variations  in  the  metabolism  of  the 
pregnant  patient,  and  are  of  interest  and  importance  to  the  obstetrician. 
The  clinical  significance  of  the  presence  of  serum-albumin  in  the  urine  in 
pregnancy  has,  after  a  closer  study  of  the  excretions,  been  found  to  have 
been  greatly  exaggerated.  In  accordance  with  the  preciseness  and  the  deli- 
cacy of  the  tests  employed  serum-albumin  has  been  found  to  be  present  by 
Schroeder  in  from  3  to  5  per  cent.;  by  Ingersley,  in  4.8  per  cent.;  by 
Flaischlen,  in  2.6  per  cent.;  by  Meyer,  in  5.4  per  cent.;  whereas  Lantos,  in 
an  interesting  series  of  observations  at  Buda-Pest,3ls  found  albumin  in  1 8 
per  cent,  of  pregnant  women  and  in  60  per  cent,  of  those  recently  delivered. 
In  39  fatal  cases  in  which  the  urine  had  contained  albumin,  the  patients  had 
suffered  from  neither  eclampsia  nor  nephritis.  The  kidneys  in  these  cases 
were  very  pale  and  anemic.  Lantos  is  convinced  that  albuminuria  is  very 
common  among  pregnant  women  :  that  it  results  from  reflex  irritation  of 
the  vasomotor  nerves  of  the  renal  vessels,  and  that  it  has  no  pathological 
significance ;  it  may,  however,  be  of  value  as  a  sign  of  pregnancy  in  making 
a  differential  diagnosis.  Peptone  has  been  found  in  the  urine  of  pregnant 
women,  and  it  is  thought  by  some  to  be  an  evidence  of  the  death  of  the 
fetus.  Thomson  319  could  not  observe  that  peptone  was  characteristic  of  the 
pregnant  condition,  nor  that  it  is  a  symptom  of  the  presence  of  a  macerated 
or  a  dead  fetus.  According  to  his  researches,  peptone  appears  intermittently 
without  appreciable  cause  in  the  urine  during  pregnancy  and  after  labor. 
Koettnitz,320  who  examined  the  urine  in  31  cases  of  pregnancy,  believes  that 
peptone  is  not  a  sign  of  fetal  death.  Its  presence  seems  to  be  a  physiological 
phenomenon,  becoming  pathological  only  when  this  substance  is  found  in 
excess.  It  has  been  found  in  complicated  labor,  when  maceration  of  the 
fetus  and  severe  visceral  disease  of  the  mother  were  present. 

The  treatment  of  albuminuria  and  peptonuria  during  pregnancy  consists 
in  interfering  with  pregnancy  and  observing  a  rational  hygiene.  As  most 
pregnant  patients  eliminate  insufficiently,  such  forms  of  diet  as  agree  best 
with  the  individual  case  should  be  enjoined.  The  peculiarities  of  the  indi- 
vidual should  be  studied  closely,  and  the  whole  range  of  therapeutic  and 
medical  art  will  frecpiently  be  taxed  to  aid  the  patient  in  solving  the  difficult 
problem  of  nourishing  herself  and  her  unborn  child.  Many  specific  treat- 
ments have  been  urged  for  albuminuria  ;  among  them  is  the  treatment  by 
benzoic  acid,  sometimes  combined  with  potassium  bicarbonate.  Various 
purgatives  have  been  given  in  these  cases,  the  best  of  these  being  those  that 
do  not  introduce  a  large  quantity  of  potassium  salts  into  the  blood  of  the 
patient.  In  general  it  may  be  said  that  the  presence  of  albumin  or  of  pep- 
tone in  the  urine  of  a  pregnant  patient  is  not  of  itself  a  pathological  phe- 
nomenon, and  it  is  only  when  the  presence  of  albumin  is  associated  with  casts 
and  deficient  excretion,  as  indicated  by  a  deficiency  in  urea,  that  the  presence 
of  albumin  becomes  an  indication  of  disease. 


THE  PATHOLOGY   OF  PREGNANCY.  277 

Abnormal  conditions  of  the  mouth  and  teeth  during  pregnancy  may 
occasion  considerable  distress  and  inconvenience  to  the  patient.  The  gums 
frequently  become  abnormally  soft,  and  a  condition  known  as  "  white  caries" 
is  often  seen  in  the  teeth.  The  edges  of  the  gums  are  thin,  pale,  somewhat 
shriveled  in  appearance,  and  retracted  from  the  teeth.  A  prominent  ridge 
along  the  free  border,  often  of  deeper  tint  than  the  surrounding  membrane, 
is  sometimes  observed.  In  other  cases  the  gums  are  reddish  and  are  appa- 
rently softened,  exuding  a  thin  fluid  or  pus  from  around  the  neck  of  the 
tooth.  Such  a  condition  does  not  inqfly  a  want  of  cleanliness,  but  appears 
to  be  a  passive  congestion  and  transudation  from  the  tissues.  It  has  been 
shown  by  Elliott  *21  and  others  that  this  condition  of  caries  in  the  teeth  results 
from  the  altered  secretions  in  the  oral  and  buccal  cavities.  The  secretion  of 
saliva  is  much  increased,  ptvalin  often  being  absent.  Early  in  the  day  the 
saliva  is  often  of  acid  reaction,  and  this  is  thought  to  have  a  potent  influence 
upon  the  development  of  caries  of  the  teeth.  This  disorder  is  sometimes 
known  as  "brown  caries"  when  extensive  discoloration  of  the  teeth  is  pres- 
ent. The  margins  of  cavities  in  these  cases  are  black.  A  line  of  brownish 
discoloration  sometimes  occurs  upon  the  upper  incisors  or  the  canines ;  the 
enamel  is  opaque.  This  form  of  caries  generally  begins  in  the  region  of  the 
bicuspids  of  the  upper  or  the  lower  jaw,  and  is  usually  found  among  patients 
of  the  lower  classes.  Softening  of  the  dentin  of  the  upper  bicuspids  and 
molars  is  sometimes  observed,  apparently  because  the  bicuspids  are  the  teeth 
against  which  fluid  is  most  forcibly  ejected  in  the  emesis  of  pregnancy;  they 
are  also  in  contact  with  the  tongue  at  rest.  General  softening  of  the  teeth 
without  actual  decay,  and  loosening  of  the  teeth  in  their  sockets  from  par- 
tial absorption  of  the  alveolus,  are  also  observed.  White  or  soft  caries  often 
occurs  without  apparent  cause  in  patients  evidently  well  nourished,  and 
resembles  osteomalacia  in  its  pathology. 

Affections  of  the  nerves  of  the  face  and  the  teeth  often  accompany  the 
structural  conditions  mentioned.  By  some,  altered  nervous  conditions  in 
these  parts  are  referred  to  pathological  conditions  in  the  mucous  membrane 
of  the  stomach.  Occasionally  pain  in  the  mouth  and  teeth  is  purely  reflex 
from  the  uterus,  as  in  a  case  described  by  Garrettson,  in  which  pain  oc- 
curred in  a  carious  tooth.  Its  removal  brought  no  relief,  but  the  healing  of 
an  ulcerated  cervix  uteri  caused  the  pain  to  disappear. 

The  treatment  of  these  conditions  consists  in  giving  proper  attention  to  the 
general  state  of  the  patient.  Locally,  potassium  chlorate  and  potassium 
bromid  are  useful  when  the  gums  are  irritable.  Powdered  boric  acid  may 
be  applied  to  the  teeth  with  a  soft  brush,  or  equal  parts  of  charcoal  and  pre- 
cipitated chalk  may  be  used  for  short  periods.  In  reflex  pain  occurring  in 
sound  teeth,  a  blister  applied  over  the  fourth  or  fifth  dorsal  vertebra  has  been 
of  use.  Absolute  alcohol  and  collodion  may  be  painted  over  a  tooth  attacked 
by  soft  caries  "When  carious  cavities  occur,  they  should  be  filled,  care  being 
taken  to  cause  the  patient  as  little  distress  as  possible  ;  the  filling  should  be 
of  a  non-irritating  character.     When  a  tooth  gives  rise  to  severe  suffering 


278  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

during  pregnancy,  there  are  many  reasons  for  advising  its  removal — preg- 
nancy has  been  interrupted  as  the  result  of  such  distress,  and  the  presence 
of  continued  pain  has  an  undoubted  influence  upon  the  development  of  the 
child. 

Exophthalmic  goiter  and  simple  goiter  may  develop  rapidly  during 
pregnancy,  and  by  the  associated  changes  that  occur  in  the  circulation  may 
result  disastrously  to  the  fetus.  Thus,  in  a  case  reported  by  Haberlin,322  the 
rapid  development  of  exophthalmic  goiter  was  accompanied  by  premature 
separation  of  the  placenta,  with  death  to  the  fetus  at  eight  months.  The 
termination  of  labor  was  followed  by  immediate  cessation  of  the  develop- 
ment of  the  goiter.  In  severe  cases  such  patients  become  very  nervous,  the 
hands  tremble  violently,  palpitation  of  the  heart  and  a  sense  of  constriction 
about  the  throat  are  present,  and  considerable  emaciation.  Vomiting  also  is 
a  symptom  in  well-marked  cases.  Although  palliative  treatment  may  relieve 
these  patients  temporarily,  if  the  symptoms  are  urgent,  the  removal  of  the 
goiter  should  promptly  be  undertaken. 

Abnormal  conditions  of  the  blood  are  not  very  infrecptent.  The  normal 
condition  of  the  blood  during  pregnancy  in  ill-nourished  women  is  that  of 
temporary  anemia,  which  soon  gives  place  to  a  development  of  physiological 
plethora  and  hyperemia.  It  has  been  shown  by  Dudner323  and  others  that 
as  soon  as  the  balance  of  nutrition  becomes  established  a  steady  increase  in 
the  number  of  corpuscles  and  the  amount  of  hemoglobin  may  be  observed. 
Narse324  found  the  specific  gravity  of  the  blood  during  pregnancy  to  be  1025. 
The  amount  of  fibrin  increases,  whereas  the  quantity  of  salts  and  hemoglobin 
diminishes.  Winckelmann323  found  that  as  pregnancy  advances  the  quantity 
of  hemoglobin  increases.  Schroeder 32c  considers  anemia  in  pregnancy  as 
an  exception  and  as  a  pathological  condition;  neither  he  nor  Meyer327  ob- 
served a  great  decrease  in  hemoglobin  or  in  corpuscles.  The  observations 
of  Ingersleff,328  Fehling,329  and  Meyer330  upon  the  comparative  composition 
of  the  blood  in  the  pregnant  and  non-pregnant  show  that  in  the  former  the 
number  of  red  corpuscles  and  the  amount  of  hemoglobin  is  slightly  decreased 
during  early  pregnancy. 

Anemia  in  the  pregnant  is  produced  by  the  same  causes  that  influence 
the  non-pregnant.  Its  recognition  is  effected  by  the  same  methods  of  exam- 
ination and  diagnosis  employed  in  the  study  of  internal  medicine.  The  con- 
dition of  anemia  complicating  pregnancy  was  early  recognized  by  American 
phvsicians,  whose  contributions  to  the  literature  of  the  subject  are  among 
the  earliest.  Cazeaux  and  the  French  school  ascribe  to  anemia  many  of  the, 
disorders  of  pregnancy.  A  curious  aversion  to  the  treatment  of  anemia 
during  pregnancy  by  methods  usually  employed  in  the  non-pregnant  is  shown 
in  the  records  of  a  malpractice  suit  reported  to  the  Obstetrical  Society  of  Lon- 
don, in  1871,  by  AVoodman,  in  which  a  physician  was  sued  for  using  ammo- 
niocitrate  of  iron  in  the  treatment  of  this  condition.  It  was  claimed  that 
he  had  thus  produced  abortion.  The  verdict  of  the  society  was  in  favor  of 
the  physician.     Gusserow331  reports  5  cases  of  extreme  anemia  in  the  preg- 


THE   PATHOLOGY    OE   PREGNANCY.  279 

nant  state.  The  eighth  month  seemed  the  period  most  favorable  for  the 
development  of  this  complication.  Bischoff  and  Biermer  report  cases  of 
oligemia  and  anemia  with  cachexia  about  this  period.332  Cameron's  excellent 
description  of  leukemia  during  pregnancy333  includes  a  case  with  a  marked 
family  history  of  leukemia.  Sanger334  reports  the  case  of  a  leukemic  mother 
who  bore  a  healthy  child,  and  also  of  a  healthy  mother  who  gave  birth  to  a 
leukemic  child.  Davis335  reports  the  case  of  a  multigravida  seized  with 
hematogenic  jaundice.  Examination  of  the  patient's  blood  revealed  the 
presence  of  pernicious  anemia.  The  blood  of  the  fetus  was  found  to  be 
normal.     Under  treatment,  her  condition  improved  greatly  after  delivery. 

Although  it  is  possible  for  these  patients  to  bear  healthy  children,  still 
pregnant  women  suffering  from  various  forms  of  anemia  and  leukemia  are 
subject  to  dangerous  complications  as  pregnancy  advances  and  as  the  patho- 
logical condition  of  the  blood  becomes  pronounced.  Important  symptoms 
are  epistaxis,  hematemesis,  and  melanemia,  with  the  development  of  a  pur- 
puric condition.  Laubenberg336  has  drawn  attention  to  the  severity  of  this 
complication  and  to  the  almost  inevitable  interruption  of  pregnancy,  and  he 
urges  the  early  induction  of  labor  as  the  duty  of  the  physician. 

The  most  serious  condition  of  the  blood  attacking  the  pregnant  patient  is 
purpura  hcemorrhagica.  Its  occurrence  and  severity  in  pregnant  women  are 
explained  by  the  sympathy  existing  between  the  utero-ovarian  and  the  tegu- 
mentary  systems  of  the  body.  This  nervous  connection  is  often  observed  in 
the  skin  eruptions  that  accompany  disorders  of  menstruation.  As  has  been 
shown  by  Immermann,  the  complication  is  sporadic  in  pregnant  patients, 
and  it  occurs  without  regard  to  family  history  or  to  previous  condition. 
Phillips m  collected  cases  illustrating  the  absence  of  a  previous  history  of 
hemophilia  in  these  patients.  In  some  of  them  hard  work  and  insufficient 
nourishment  seem  to  have  produced  the.  disorder.  Profound  mental  dis- 
turbance has  been  followed  occasionally  by  this  condition.  In  Phillips'  case 
the  child  showed  no  symptoms  of  purpura,  and  the  mother  recovered  rapidly 
after  labor.  Kaezmarsky  M8  reports  a  case  in  which  severe  sacral  pain  during 
pregnancy  was  the  earliest  symptom.  The  birth  of  a  dead  fetus  speedily 
followed,  and  the  mother  perished  from  hemorrhage.  Dohrn  reports  twin 
pregnancy  with  this  complication,  with  severe  postpartum  hemorrhage  and 
death.  Both  these  patients  had  previously  been  healthy.  Wernicke,  Reck- 
linghausen, Hanot,  and  Luzet  offer  evidence  that  seems  to  prove,  on  the  one 
hand,  that  the  disorder  is  a  form  of  infection  by  bacilli ;  on  the  other  hand, 
the  cases  described  by  Dohrn  m  do  not  point  to  this  condition  as  causative. 
The  immunity  of  the  fetus  in  these  cases  is  inexplicable  and  of  interest. 
Microscopical  study  made  of  the  blood  in  this  complication  by  Gibbon  dur- 
ing the  height  of  an  attack  of  purpura  showed  that  the  red  corpuscles 
contained  numbers  of  black  granules  massed  together  in  some  of  the  cells. 
These  bodies  increased  as  the  disorder  became  severe  and  diminished  in  con- 
valescence. The  corpuscles  numbered  over  5,000,000  in  a  cubic  millimeter 
early  in  the  disease,  this  number  being  greatly  diminished  as  the  disorder 


280  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

progressed.  The  white  corpuscles  became  excessive,  and  the  hemoglobin 
fell  to  30  per  cent.,  afterward  rising  to  60  per  cent. 

The  treatment  of  anemia  and  leukemia  complicating  pregnancy  consists  in 
securing  thorough  elimination,  and  in  the  employment  of  those  forms  of 
treatment  found  useful  in  the  non-pregnant  patient.  Osier340  obtained  good 
results  from  the  persistent  use  of  arsenic,  the  free  use  of  iron,  the  inhalation 
of  oxygen,  systematic  and  forced  feeding,  and,  of  great  importance,  the 
correction  of  the  condition  of  gastro-intestinal  catarrh  so  often  found  in 
these  cases.  The  patient's  strength  should  be  conserved  in  every  possible 
manner.  Should  purpuric  eruption  develop  with  hemorrhages,  antiseptic 
dressings  must  be  applied  over  these  areas ;  bichlorid  of  mercury  should  not 
be  employed,  the  susceptibility  of  anemic  pregnant  patients  to  mercurial 
poisoning  being  a  contra-indication  to  its  use.  Bichlorid  of  mercury  should 
be  given  in  minute  closes  when  a  possible  syphilitic  taint  is  suspected  as  a 
complication.  The  prompt  induction  of  labor  is  indicated  in  cases  in  which 
the  disorder  steadily  increases  in  severity,  although  this  procedure,  when  the 
patient  is  in  a  critical  condition,  is  useless  and  unjustifiable.  If  the  induc- 
tion of  labor  is  decided  on,  it  should  be  done  promptly  and  while  the  patient 
still  has  sufficient  strength  to  justify  the  hope  of  recovery. 

The  influence  of  pregnancy  upon  the  alkalinity  of  the  blood  has  been 
studied  by  Blumreich.341  He  finds  that  the  difference  in  the  alkalinity  of  the 
blood  occasioned  by  pregnancy  is  less  in  mankind  than  in  animals.  The 
increased  alkalinity  is  not  due  especially  to  an  increase  in  the  red  blood- 
corpuscles.  This  increased  alkalinity  progresses  steadily  throughout  preg- 
nancv,  and  in  some  cases  is  accompanied  by  a  low  specific  gravity.  In  4 
cases  alkalinity  diminished  markedly  after  the  birth  of  the  child.  In  contrast 
with  those  patients  who  are  pregnant,  the  low  alkalinity  in  the  non-pregnant 
is  very  marked. 

Cardiac  disease  complicating-  pregnancy  is  not  infrequently  observed. 
In  those  patients  who  are  well  nourished  slight  cardiac  lesions  frequently 
remain  undetected  during  pregnancy  and  give  rise  to  no  embarrassment  at 
labor.  A  physiological  hypertrophy  of  the  heart  occurring  during  pregnancy 
is  well  described  by  Larchner,  who  found  hypertrophy  of  the  left  ventricle 
in  pregnant  women.  Other  observers  assert  that  this  hypertrophy  is  asso- 
ciated with  dilatation  of  the  right  heart.  Istria343  and  others  maintain  that 
pregnancy  often  induces  endocarditis,  and  various  observers  have  noted  the 
development  of  endocarditis  after  repeated  parturition.  The  most  fatal  of 
these  lesions  in  the  pregnant  patient  is  mitral  stenosis.  Marshall i43  and 
Duckworth  demonstrated  the  remarkable  preponderance  of  this  form  of 
heart  disease  in  women.  Direct  cardiac  symptoms  are  comparatively  few, 
consisting  of  palpitation,  and  at  times  of  pain  and  depression.  Bronchial 
catarrh  is  generally  observed.  The  want  of  concurrence  between  the  cardiac 
systole  and  the  impulse  given  by  the  pulse-wave  is  an  interesting  and 
important  diagnostic  point  in  these  cases.  Cases  reported  by  Fritsch,  Budin, 
Macdonald,  and  Malherbe  illustrate  the  occurrence  and  fatal  termination  of 


THE   PATHOLOGY   OF  PREGNANCY.  281 

this  disorder.  Death  occurred  as  the  result  of  this  lesion  in  9  out  of  14 
cases  reported  by  Macdonald.  Of  13  cases  seen  by  Porak,  8  proved  fatal. 
In  19  cases  observed  by  Remy  11  were  fatal.  In  double  mitral  lesion  7  out 
of  8  of  Hart's  cases  perished.  In  one-half  of  the  cases  recorded  pregnancy 
was  interrupted  without  interference.  Half  of  these  patients  died  and  half 
of  them  recovered.  The  predominance  of  pulmonary  symptoms  in  mitral 
stenosis  should  be  borne  in  mind  in  making  a  diagnosis  and  in  instituting 
treatment. 

While  the  mortality  of  pregnancy  complicated  by  mitral  stenosis  is 
more  than  50  per  cent.,  aortic  lesions  give  a  mortality  of  23  per  cent. 
Mitral  insufficiency  is  accredited  with  13  per  cent.,  whereas  in  complex 
lesions  of  the  heart  a  mortality  of  50  per  cent,  is  a  conservative  estimate. 
The  prognosis  for  the  continuance  of  pregnancy  and  for  the  life  of  the  child 
is  distinctly  unfavorable.  Mackness344  reports  a  case  of  pregnancy  compli- 
cated by  aortic  and  mitral  disease  in  which  labor  was  induced,  and  partial 
recovery  ensued.  The  patient  became  so  prostrated  by  persistent  emesis  and 
paroxysms  of  oppression  during  the  latter  portion  of  her  pregnancy  as  to 
require  vigorous  stimulation.  The  emesis  and  paroxysms  of  oppression  were 
relieved  by  the  administration  of  amyl  nitrite. 

Merklen345  reports  an  illustrative  case  in  which  pulmonary  tuberculosis 
was  associated  with  stenosis  at  the  mitral  orifice.  Dilatation  of  both  sides 
of  the  heart  was  present,  with  general  anasarca  and  exaggerated  pulmonary 
congestion.  Venous  stasis  in  the  kidneys  was  well  pronounced.  Pulmonary 
hemorrhage  occurred  and  proved  a  temporary  relief  to  the  patient. 

Pinard,**6  in  describing  valvular  heart  disease  in  pregnancy,  does  not 
believe  that  pregnancy  in  itself  predisposes  to  heart-lesions.  In  women  who 
have  cardiac  disease  and  who  become  pregnant,  compensation  is  established 
if  the  kidneys  are  sound.  In  treating  these  cases  absolute  rest,  milk  diet 
after  the  fourth  month,  and  infusions  of  digitalis  have  been  used  successfully. 
If  syncope  and  complications  arise,  he  urges  that  the  uterus  be  emptied  and 
that  the  patient  be  bled. 

Hemoptysis  complicating  pregnancy  may  be  due  to  simple  pulmonary 
congestion  in  cases  of  valvular  heart  disease,  or  may  result  from  disease  of 
the  parenchyma  of  the  lung,  most  commonly  tubercular.  Martin  U1  describes 
the  case  of  a  patient,  four  months  pregnant,  who  suffered  from  obstinate  and 
persistent  hemoptysis.  There  were  pulmonary  signs  of  consolidation  anteri- 
orly below  the  right  clavicle.  Hemorrhage  occurred  at  about  the  time  when 
the  patient  would  have  menstruated  had  she  not  been  pregnant.  Epistaxis 
subsequently  developed,  and  later  a  profuse  red  rash,  resembling  that  of 
scarlatina,  covered  the  body.  This  rash  gradually  faded,  and  was  not 
attended  by  fever  or  any  signs  of  other  complication.  Pulmonary  symptoms 
improved  slowly,  especially  under  treatment  by  a  succession  of  blisters  upon 
the  chest,  which  gave  marked  relief.  The  patient  recovered  completely  and 
the  pregnancy  terminated  normally. 

Hemorrhage  from  the  Uterus. — The  fact  that  profuse  hemorrhage  from 


282  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

the  uterus  may  occur  during  pregnancy  and  the  patient  yet  go  on  to  the  end  of 
o-estation  is  well  illustrated  in  a  case  described  by  Robertson.348  His  patient 
was  a  multigravida  who  had  several  hemorrhages  so  severe  as  to  lead  to  the 
belief,  on  each  occasion,  that  abortion  had  occurred.  Pregnancy  continued 
to  a  successful  termination. 

Internal  uterine  hemorrhage  is  observed  as  a  complication  in  patients  suf- 
fering from  nephritis  during  pregnancy.  Symptoms  of  shock  and  acute  ane- 
mia may  be  present  to  such  an  extent  that  the  presence  of  placenta  prsevia  has 
been  suspected  in  these  cases.  Schauta  m  reports  the  case  of  a  woman,  aged 
forty-four,  who  had  borne  9  children,  and  in  whom  the  occurrence  of  pro- 
fuse hemorrhage  led  to  a  diagnosis  of  placenta  prsevia.  Although  the  patient 
was  not  in  labor,  the  os  was  dilated  sufficiently  to  ascertain  the  absence  of 
placenta  prsevia.  Transfusion  by  normal  salt  solution  was  performed  imme- 
diately, and  when  the  patient  rallied,  the  child,  which  was  dead,  was  extracted 
by  craniotomy.  A  large  quantity  of  clotted  blood  was  found  in  the  uterus 
and  vagina.  The  patient  succumbed  from  the  hemorrhage  shortly  after 
delivery.  The  postmortem  examination  revealed  chronic  nephritis  as  the 
only  complication  accounting  for  the  condition.  Winter  observed  3  similar 
cases  in  Schroeder's  clinic. 

3.  Acute  Infections  During  Pregnancy. 

The  condition  of  pregnancy  renders  the  patient  peculiarly  liable  to  the 
rapid  development  of  infective  germs.  The  body  of  the  pregnant  woman 
presents  that  condition  of  plethora  and  hyperemia  in  the  viscera  that  invites 
the  growth  of  bacteria.  It  is  not  difficult,  then,  to  understand  why  these 
complications  of  pregnancy  are  among  the  most  severe.  First  among  these 
disorders  may  be  considered  those  in  which  the  infection  usually  gains  access 
to  the  body  through  the  genital  tract.  Among  such  disorders  are  gonorrhea, 
syphilis,  and  cancer. 

Gonorrhea  is  by  no  means  an  uncommon  complication  of  pregnancy,  and 
in  an  ignorant  woman  no  intelligent  history  attracting  the  attention  of  the 
physician  to  the  condition  present  may  be  afforded.  The  complaint  of  diffi- 
culty in  micturition  and  of  burning  and  irritant  discharge  should,  however, 
occasion  an  examination,  when  specific  vaginitis  may  be  detected.  The 
symptoms  and  treatment  of  this  disorder  in  the  pregnant  are  essentially  the 
same  as  those  in  the  non-pregnant,  but  the  pathology  of  the  condition  is 
more  complex  and  of  greater  import.  Not  only  may  the  gonococci  infect 
the  mucous  membrane  of  the  vagina,  and  possibly  cause  abscess  of  Bartho- 
lin's glands,  with  occasional  acute  inflammation  of  the  rectum  and  the  sur- 
rounding tissues,  but  the  endometrium  also  may  be  attacked,  and  even  the 
fetus  may  be  infected  in  utero  by  the  gonorrheal  virus.  Children  have  been 
born  with  gonorrheal  ophthalmia,  and  under  circumstances  that  precluded 
the  possibility  of  infection  during  birth.  Such  infection,  however,  is  of 
comparatively  slight  importance  when  compared  with  the  clangers  arising  to 
the  mother  from  the  development  and  retention  of  gonorrheal  infection  in 


THE  PATHOLOGY   OF  PREGNANCY.  283 

the  tissues  about  the  uterus  and  in  the  tubes  and  ovaries.  The  entire  genito- 
urinary tract  of  the  mother  is  liable  to  such  infection,  the  consequences 
of  which  may  not  become  apparent  until  some  time  after  delivery.  Thus, 
in  the  writer's  experience  a  patient  perished  from  the  sudden  and  acute  sep- 
tic infection  occasioned  by  the  spontaneous  rupture  of  a  small  gonorrheal 
ovarian  abscess  occurring  two  weeks  after  delivery.  This  patient's  puerperal 
period  had  apparently  been  normal,  and  the  infection  must  have  been  received 
before  or  during  pregnancy.  The  same  observer  witnessed  death  from 
nephritis  in  which  the  genito-urinary  tract  had  been  the  seat  of  gonorrheal 
infection  during  pregnancy.  In  this  case  the  tubes  and  ovaries  escaped,  but 
the  bladder  and  kidneys  showed  abundant  infective  germs.  The  presence 
of  gonorrhea  as  a  complication  of  pregnancy  should  lead  to  prompt  anti- 
sepsis of  as  much  of  the  genital  tract  as  is  accessible.  If  the  bladder  is 
invaded,  it,  too,  should  be  subjected  to  the  same  thorough  antisepsis.  At 
the  time  of  labor  all  possible  precautions  should  be  taken  to  avoid  violence 
to  the  uterus  or  its  appendages  that  may  set  free  retained  gonorrheal  poison. 
During  the  puerperal  period  the  occurrence  of  septic  inflammation  in  and 
about  the  uterus  should  be  treated  promptly  by  intra-uterine  antisepsis,  or 
by  abdominal  incision  as  soon  as  possible.  It  is  folly  to  treat  the  insidious 
ravages  of  gonorrhea  in  the  connective  tissue,  the  peritoneum,  and  contents 
of  the  pelvis  occurring  after  labor  by  any  but  prompt  surgical  measures. 
Exploratory  abdominal  incision  is  far  more  conservative  in  these  cases  than 
delay. 

Cumston  ^°  reviews  the  literature  of  the  puerperal  state  as  affected  bv 
gonorrhea,  and  concludes  that  no  definite  symptomatology  for  a  gonorrheal 
process  during  the  puerperal  period  has  been  clearly  described.  Gonorrhea 
does  not  appear  to  produce  fever  if  the  process  does  not  extend  above  the 
internal  os,  and  some  describe  cases  in  which  a  gonorrheal  catarrh  of  the 
cervix  extended  to  the  endometrium  without  serious  symptoms.  If  fever 
does  occur,  it  may  take  place  as  early  as  the  third  day.  Authorities  agree 
that  gonorrhea  runs  a  milder  course  in  many  cases  during  the  puerperal 
period  than  in  non-puerperal  patients.  As  regards  the  result  of  gonorrhea, 
a  pyosalpinx,  if  present  in  one  tube  only,  will  not  interfere  with  pregnancy  ; 
sterility  is  due  largely  to  endometritis  or  salpingitis.  Cumston  reports  5 
cases  of  gonorrhea  complicating  the  puerperal  period.  In  1  patient  a  mild 
gonorrhea  during  pregnancy  was  followed  by  fever  and  exudate  in  the  puer- 
peral period.  Both  disappeared,  and  the  child  escaped  infection.  In  the 
second  case  the  patient  was  infected  soon  after  parturition,  and  the  symptoms 
subsided  after  curetting  the  uterus  and  applying  carbolic  acid.  The  child 
also  escaped.  In  the  third  case  thrombosis  of  the  veins  in  both  lower  extremi- 
ties occurred,  with  a  mass  extending  across  the  pelvis  and  finally  breaking 
down  with  high  fever.  Posterior  vaginal  colpotomv  was  performed,  liberat- 
ing thick,  yellowish-green  pus.  Total  abdominal  hysterectomy  was  per- 
formed later  for  severe  pain  and  rectal  symptoms.  The  patient  made  a  fair 
recovery.     In  the  fourth  case  the  right  knee-joint  was  swollen  and  painful, 


284  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

and  the  parametrium  was  thickened  and  the  uterus  retroverted.  The  patient 
made  a  tedious  recovery. 

Syphilitic  infection  during  pregnancy  in  many  cases  runs  the  usual 
course  of  this  disorder,  and  in  others  it  assumes  peculiar  malignancy.  Patho- 
logically speaking,  the  virulence  of  syphilitic  infection  in  pregnancy  depends 
not  only  upon  the  patient's  powers  of  resistance,  but  also  upon  septic  germs 
that  may  be  associated  with  the  bacillus  of  syphilis.  Some  of  the  most 
malignant  types  of  puerperal  sepsis  are  observed  in  patients  who  become 
syphilitic  at  conception  or  during  pregnancy.  In  these  patients  the  syph- 
ilitic eruption  is  so  masked  and  exaggerated  by  the  septic  element  present  as 
to  occasion  great  difficulty  in  diagnosis.  The  writer  recalls  a  case  of  this 
sort  in  which  close  study  by  Kaposi  was  necessary  to  differentiate  between 
an  acute  syphilitic  exanthem  and  septic  infection.  Hirigoyen m  describes 
the  occurrence  of  syphilis  in  34  patients,  who  comprised  5  per  cent,  of  the 
total  number  of  pregnancies  under  observation.  Other  statistics  seem  to 
indicate  that  in  large  cities  this  percentage  is  the  usual  one  in  pregnancy. 

The  influence  which  pregnancy  exerts  upon  women  already  syphilitic  has 
been  described  by  Fournier,  who  laid  down  the  maxim  that  a  syphilitic 
woman  who  becomes  pregnant  is  much  more  likely  to  abort  than  is  a  preg- 
nant woman  who  becomes  syphilitic.  The  duration  of  the  syphilis  exercises 
a  very  distinct  influence  upon  the  prognosis  of  the  pregnancy  :  the  longer 
the  woman  has  been  syphilitic  before  the  pregnancy  occurs,  provided  she  has 
not  been  subjected  to  efficient  treatment,  the  graver  is  the  prognosis  for  the 
continuance  of  the  pregnancy  and  the  life  of  the  fetus.  The  prognosis  of 
pregnancy  is  also  very  serious  the  earlier  in  the  pregnancy  the  infection 
occurs  ;  thus,  the  majority  of  pregnancies  complicated  by  syphilitic  infection 
occurring  during  the  first  four  months  result  in  the  death  of  the  fetus. 
When  infection  occurs  from  the  fourth  to  the  sixth  month  of  pregnancy,  50 
per  cent,  of  children  are  lost.  During  the  last  three  months  of  pregnancy 
the  complication  of  syphilis  results  in  the  death  of  less  than  half  of  the 
children.  The  general  fetal  mortality  in  syphilis  is,  under  the  best  circum- 
stances, 75  per  cent. 

The  mother's  health  in  pregnancy  complicated  by  syphilis  is  liable  to 
rapid  deterioration  if  the  syphilitic  process  be  acute.  The  stimulus  of  preg- 
nancy seems  to  facilitate  the  spread  of  the  poison  and  the  various  lesions 
that  arise  from  it.  To  be  efficient,  antisyphilitic  treatment  should  begin  as 
soon  as  the  infection  occurs,  and  the  earlier  in  the  pregnancy  such  treatment 
is  begun,  the  better  are  the  results  obtained.  Local  treatment  of  syphilitic 
lesions  complicating  pregnancy  consists  in  thorough  cleanliness  and  in  the 
maintenance,  so  far  as  possible,  of  local  antisepsis.  Ulcers  should  be  dusted 
with  calomel  and  iodoform ;  the  parts  should  be  kept  thoroughly  clean  with 
antiseptic  douches,  and  the  discharges  from  syphilitic  patients  should  be 
received  upon  absorbent  material,  which  is  then  burned.  Antisyphilitic 
medication  is  to  be  conducted  in  accordance  with  the  therapeutics  of  this 
disorder  in  the  non-pregnant.     Mercury  biniodid,  mercury  bichlorid,  calomel, 


THE   PATHOLOGY    OF  PREGNANCY.  285 

gray  powder,  and  the  bichlorid  hypodermically  are  all  of  use.  Inunctions 
with  mercurial  ointment  are  found  to  be  advantageous  in  many  cases.  In 
those  patients  with  whom  mercury  does  not  agree  potassium  iodid  in  combi- 
nation with  iodin  may  be  used  to  advantage.  The  following  mixture  has 
proved  efficacious  in  a  number  of  cases : 

Tfy     Iodin,  gr.  iv ; 

Iodid  of  potassium,  giv; 

Compound  syrup  sarsaparilla,  siv. 
Dose. — One  teaspoonful  after  meals. 

Besnier352  obtained  good  results  with  a  pill  containing  ^  of  a  grain  of 
mercury  bichlorid  with  T^  of  a  grain  of  extract  of  opium  and  -A-  of  a  grain 
of  extract  of  gentian  rubbed  up  with  glycerin. 

Equally  important  with  the  specific  treatment  of  syphilis  in  pregnancy  is 
the  tonic  treatment  these  cases  demand.  Well-ordered  feeding,  in  which  an 
abundance  of  fat,  as  in  cod-liver  oil  or  other  forms,  is  included,  and  the  per- 
sistent administration  of  iron,  arsenic,  nux  vomica,  and  such  substances  as 
stimulate  digestion,  are  of  the  greatest  importance.  The  aim  of  the  physician 
must  not  be  simply  to  tear  down  diseased  tissue,  but  to  build  up  that  which 
is  sound.  The  results  of  such  treatment  are  often  most  gratifying.  The 
characteristic  lesions  of  syphilis  fade  with  great  rapidity  in  these  cases ;  the 
patient,  who  may  have  aborted  repeatedly,  goes  on  nearly  or  quite  to  term, 
and  a  fairly  well-developed  and  healthy  child  is  born.  On  the  other  hand, 
neglect  or  inadequate  treatment  often  results  in  sad  ravages  in  the  mother's 
tissues,  ending  very  frequently  in  fetal  death. 

Murray353  draws  attention  to  the  pathology  and  diagnosis  of  syphilis 
during  pregnancy  and  states  that  he  has  found  inunctions  of  mercurial  oint- 
ment the  most  efficient  treatment.  If  seen  before  the  third  month,  from  40 
to  50  per  cent,  of  cases  were  carried  through  pregnancy  by  this  means.  He 
drew  attention  to  the  fact  that  the  first  syphilid  may  appear  ivpou  the  ton- 
sils. The  child  should  be  treated  through  the  mother's  milk  and  later  by 
inunctions. 

Cancer  complicating  pregnancy  affects  the  course  of  gestation  chiefly  in 
its  local  manifestations  in  the  genital  tract.  In  rare  instances  multiple  sar- 
comata develop  with  great  rapidity  in  various  portions  of  the  body,  termi- 
nating in  death  by  constitutional  infection.  In  other  instances  cancer  of  the 
uterus  by  metastasis  speedily  reduces  the  patient  to  a  condition  of  threat- 
ened collapse,  often  resulting  in  constitutional  septic  infection.  In  such 
cases  the  interruption  of  pregnancy  is  probably  of  little  avail  for  the  patient, 
except  in  so  far  as  the  malignancy  of  the  cancerous  process  seems  less  acute 
if  the  uterus  is  emptied. 

Fehling3"4  observed  5  cases  of  cancer  of  the  cervix  in  3000  cases  of  preg- 
nancy. In  the  early  months  of  pregnancy  he  urges  vaginal  extirpation  of 
the  uterus,  and  in  the  later  months  Cesarean  operation  followed  by  amputa- 


286  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

tion  of  the  uterus  with  removal  of  the  cervix  through  the  vagina.  He 
describes  5  cases  treated  after  this  method  with  as  good  results  as  the  nature 
of  the  disease  permits.  Reckmann 3:'5  describes  a  method  of  operation  in  a 
case  six  months  advanced  and  complicated  by  cancer  of  the  cervix.  The 
cervix  was  first  thoroughly  curetted  and  cauterized,  and  the  broad  ligaments 
were  ligated  with  catgut.  The  uterus  was  drawn  down,  and  the  cervix  was 
incised  so  as  to  split  the  uterus.  The  fetus  and  its  appendages  were  then 
removed.  The  uterus  was  next  retroverted  and  removed  in  the  usual 
manner.     An  excellent  result  followed. 

Apparent  recoveries  from  cancer  sometimes  puzzle  the  physician  and  lead 
him  to  question  the  accuracy  of  his  diagnosis.  Coe 356  reports  a  very  inter- 
esting case  in  which  a  primipara,  aged  forty-two,  had  papillomatous  disease 
of  the  cervix,  for  which  curetting  and  the  application  of  iron  were  employed 
by  Reynolds.  Microscopical  examination  of  the  mass  removed  resulted  in 
a  diagnosis  of  carcinoma.  The  patient  became  pregnant  and  was  seen  by 
Coe  when  pregnancy  was  four  and  a  half  months  advanced,  when  she  objected 
to  the  induction  of  abortion,  as  she  hoped  to  save  the  child.  When  labor 
came  on,  a  Barnes  bag  was  inserted  to  soften  the  cicatricial  ring.  The  head 
of  the  child,  fortunately,  was  small,  and  the  child  was  delivered  by  forceps. 
The  patient  made  a  good  recovery.  The  uterus  underwent  perfect  involu- 
tion and  a  portion  of  the  cervix  was  excised,  and  no  evidence  of  cancer  found. 
The  patient  resumed  her  occupation.  She  reported  about  a  year  after,  when 
malignant  disease  of  the  cervix  was  plainly  evident.  Vaginal  hysterectomy 
was  performed,  and  the  upper  fourth  of  the  vagina  also  was  removed.  This 
patient  apparently  made  a  good  recovery  after  the  operation. 

Typhoid  infection  during  pregnancy  seriously  threatens  the  mother's 
convalescence  from  labor,  and  frequently  results  in  the  death  of  the  fetus. 
In  a  case  described  by  Findlay357  the  patient's  husband  had  been  ill  for  some 
time  with  typhoid  infection.  Her  pregnancy  terminated  at  about  the  expected 
time,  labor  occurring  with  a  temperature  of  103°  F.  and  a  pulse  of  140. 
The  uterus  contracted  well,  although  intestinal  peristalsis  was  active  during 
labor  and  the  patient  had  diarrhea,  which  subsided  after  delivery.  ISTo  milk 
was  secreted,  and  the  breasts  gave  no  signs  of  activity.  The  skin  of  the 
child  was  shriveled,  and  after  a  few  days  it  exhibited  an  eruption  with  bul- 
lous spots,  the  scars  of  which  persisted  when  the  child  had  reached  adult 
life.  Pregnancy  is  interrupted  in  these  cases  by  continued  high  temperature, 
by  hemorrhage  in  the  endometrium  or  in  the  membranes  of  the  ovum  itself, 
and  by  a  depressed  condition  of  the  maternal  circulation,  with  asphyxiation, 
of  the  child.  Kaminski,  Zulzer,  and  Scanzoni  observed  interruption  of 
pregnancy  in  two-thirds  of  their  cases.  The  fact  that  the  fetus  may  become 
infected  by  the  transmission  of  the  germs  of  typhoid  through  the  placenta 
has  been  demonstrated  by  Giglio.358  The  latter  examined  carefully  a  fetus 
and  its  appendages  born  of  a  mother  suffering  from  typhoid  fever  in  an 
epidemic  at  Palermo.  Pregnancy  terminated  forty-six  davs  after  the  begin- 
ning of  the  fever.     Although  the  specimen  appeared  to  be  normal  on  casual 


THE   PATHOLOGY    OF  PREGNANCY.  287 

examination,  cultures  of  the  maternal  blood  demonstrated  the  presence  of 
the  typhoid  germ,  whereas  cultures  from  the  milk  revealed  bacteria  closely 
resembling  those  obtained  from  a  typhoid  non-pregnant  patient.  The  fetus 
and  its  appendages  also  contained  typhoid  bacilli.  Boyd359  reports  a  case  in 
which  premature  labor  occurred  a  week  after  the  fever  began.  The  patient 
finally  succumbed  after  continued  high  temperature. 

The  diagnosis  of  typhoid  fever  complicating  pregnancy  presents  no  espe- 
cial difficulty.  Should  the  physician  see  the  case  during  the  puerperal 
period,  it  must  not  be  mistaken  for  puerperal  sepsis,  nor  should  puerperal 
sepsis  complicated  by  diarrhea  be  mistaken  for  typhoid  fever.  It  will  be 
remembered  that  in  septic  cases  diarrhea  is  a  not  infrequent  symptom.  The 
treatment  of  typhoid  fever  during  pregnancy  should  be  directed  to  control- 
ling the  temperature  and  to  maintaining  the  patient's  strength.  The  treat- 
ment of  pyrexia  by  the  bath  and  pack  is  especially  suitable  in  these  cases. 
The  latter  is  most  efficacious  when  the  very  energetic  application  of  cold  had 
a  tendency  to  prostrate  the  patient.  Xo  fear  need  be  felt  regarding  the 
induction  of  labor  by  treatment  addressed  to  controlling  the  temperature,  for 
it  will  not  be  such  treatment,  but  its  failure  to  modify  the  fever,  that  will 
bring  about  a  premature  ending  of  gestation.  The  fact  that  in  many  preg- 
nant patients  suffering  from  typhoid  the  stomach  is  exceedingly  irritable  will 
lead  the  physician  to  abstain  from  the  administration  of  drugs  by  the  stomach 
so  far  as  possible. 

Le  Page360  reports  8  cases  of  typhoid  infection  complicating  pregnancy 
and  the  puerperal  state.  In  many  of  these  it  was  impossible,  from  the 
clinical  phenomena  alone,  to  say  that  puerperal  septic  infection  was  not 
present.  The  serum  method  of  diagnosis  gave  positive  results  in  each  case. 
A  number  of  the  cases  were  found  to  have  come  from  a  locality  where 
typhoid  infection  was  epidemic.  Others  were  sporadic  cases  whose  place 
of  origin  could  not  be  discovered.  Le  Page's  paper  calls  attention  to  the 
value  of  the  serum  diagnosis  in  these  cases. 

Erysipelas  occurring  during  pregnancy  is  infrequent,  and  it  is  grave  or 
mild  according  as  it  is  or  is  not  accompanied  by  other  forms  of  septic  germs. 
Facial  erysipelas  may  occur  in  the  pregnant  patient  and  give  rise  to  abortion 
without  the  development  of  puerperal  sepsis.  Such  a  result,  however,  is 
possible  only  when  strict  antiseptic  precautions  have  been  observed.  Ery- 
sipelas of  the  genital  tract — or  of  the  lower  extremities,  in  which  case  the 
infective  germ  gains  ready  access  to  the  genital  tract — results  almost  invari- 
ably in  puerperal  septic  infection. 

The  symptoms  of  erysipelas  complicating  pregnancy  do  not  differ  essen- 
tially from  those  of  erysipelas  in  the  non-pregnant  patient. 

The  treatment  consists  in  carefully  supporting  the  patient's  strength,  and 
in  avoiding  all  unnecessary  examinations  and  manipulations  in  the  genital 
tract,  as  interference  with  this  portion  of  the  patient's  body  adds  to  the  risk 
of  infection.  Smith361  reports  the  case  of  a  woman,  six  months  pregnant, 
who  injured  her  knee.     Erysipelas  developed  in  the  thigh  eight  days  after- 


288  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

ward,  and  was  followed  by  a  large  abscess  burrowing  beneath  the  muscles. 
Premature  labor  occurred  at  seven  and  a  half  months.  The  puerperal  period 
was  normal,  and  the  child  survived.  In  a  recent  case  of  facial  erysipelas 
under  the  observation  of  the  writer,  the  mother  suffered  but  slight  incon- 
venience from  the  infection,  but  gestation  terminated  prematurely,  the  child 
surviving. 

Erysipelas  of  the  face  and  head  seems  to  affect  the  fetus  in  many  cases 
quite  as  markedly  as  erysipelas  of  the  pelvic  organs.  Colin  m  reports  a 
case  of  facial  erysipelas  at  eight  months'  pregnancy.  The  fetus,  prematurely 
born,  showed  upon  the  correspondmg  portions  of  the  head  and  face  an 
edematous  red  swelling  .that  gradually  faded,  followed  by  descpiamation. 
Examination  of  the  infiltrated  tissues  for  erysipelas  germs  gave  negative 
results.  The  child  perished  from  multiple  abscess  in  the  kidneys.  A  simi- 
lar condition  of  the  fetus  has  been  described  by  Runge,  Kaltenbach,  and 
Stratz. 

Measles. — Of  about  the  same  relative  virulence  as  erysipelas  is  the  infec- 
tion of  measles  attacking  the  pregnant  patient.  The  symptomatology  of  this 
disorder  occurring  during  gestation  does  not  differ  essentially  from  that 
observed  in  the  non-pregnant.  If  the  bronchitis  usually  accompanying 
measles  is  severe,  the  incessant  cough  and  movements  of  the  abdominal  walls 
thus  occurring  greatly  increase  the  probability  of  abortion.  At  birth  the 
child  may  exhibit  an  anomalous  eruption  or  it  may  apparently  escape.  The 
prognosis  of  measles  complicating  pregnancy  is  to  be  based  upon  the  severity 
of  the  infection,  and  especially  upon  the  continuance  of  high  temperature. 

The  infection  of  measles  may  be  transmitted  from  mother  to  child,  as 
illustrated  by  a  case  reported  by  Lomer  ;363  the  child  perished  from  intestinal 
catarrh  ;  the  mother  recovered.  The  characteristic  eruption  appeared  on  the 
child's  forehead  and  breast  a  few  hours  after  birth.  Gautier364  found  measles 
transmitted  from  mother  to  fetus  in  6  out  of  11  cases ;  the  maternal  mor- 
tality of  the  11  cases  was  2. 

Salus365  has  collected  13  cases  of  measles  complicating  pregnancy,  in 
which  the  pregnancy  was  interrupted  in  10.  The  children  born  of  mothers 
having  measles  did  not,  as  a  rule,  show  evidence  of  the  infection,  but  hemor- 
rhage has  been  observed  on  the  maternal  aspect  of  the  placenta,  bringing 
about  a  premature  separation  and  premature  labor.  On  microscopical  exam- 
ination, bleeding  was  found  in  the  spongy  layer  of  decidua,  with  great 
dilatation  of  the  vessels. 

Jardine  366  reported  2  cases  of  measles  occurring  in  puerperal  women  from 
the  Glasgow  Maternity  Hospital.  In  1  the  puerperal  period  was  normal 
until  the  seventh  day,  when  measles  appeared.  The  source  of  infection  was 
traced  to  the  house  in  which  the  patient  lodged  before  coming  to  the  hospital. 
In  the  second  case  the  rash  of  measles  was  just  beginning  to  appear  in  the 
first  stage  of  labor.  Labor  was  normal,  and  the  child  showed  no  signs  of 
measles  two  weeks  after  its  birth.  He  had  seen  the  ease  of  a  child  suffering 
from  measles  who  was  placed  in  bed  beside  a  woman  delivered  on  the  day 


THE  PATHOLOGY   OF  PREGNANCY.  289 

previous.  The  mother  escaped,  but  the  new-born  child  developed  measles. 
In  discussion  a  case  was  narrated  in  which  a  mother  nursed  a  child  having 
measles  and  scarlatina  and  herself  remained  immune. 

Scarlatina  is  a  serious  complication  of  pregnancy,  and  its  virulence  is 
apparent  from  the  great  promptitude  with  which  it  affects  the  fetus  in  utero. 
The  fact  that  the  germ  of  scarlatina  is  morphologically  held  by  many 
observers  to  be  identical  with  various  forms  of  septic  bacteria  renders  scar- 
latinal infection  of  grave  import.  An  illustrative  case  is  reported  by  Bal- 
lantyne  and  Milligan,367  in  which  the  infection  occurred  during  the  seventh 
month  of  pregnancy.  Two  days  later  gestation  terminated,  and  the  fetus 
was  found  to  have  scarlatina. 

In  21  cases  of  scarlatina  occurring  during  pregnancy,  Meyer368  found  it 
impossible  to  trace  the  medium  of  contagion.  The  incubation  period  was 
from  three  to  five  days.  In  6  out  of  21  cases  the  disease  ran  a  mild  course 
without  complications.  In  8  cases  sepsis  occurred,  with  2  deaths.  The 
resemblance  of  puerperal  scarlatina  to  diphtheric  infection  of  wounds  was 
strikingly  illustrated  in  Meyer's  complicated  cases.  The  interruption  of 
pregnancy  by  scarlatina  is  well  illustrated  by  Remy  ;369  abortion  occurred  at 
five  months,  the  patient  making  an  uncomplicated  recovery. 

Variola  resembles  scarlatina  in  its  infective  energy  and  in  the  rapid- 
ity with  which  it  is  transmitted  to  the  fetus.  It  possesses  the  fortunate 
distinction,  however,  of  being  susceptible  to  modification  by  vaccination. 
Whereas  pregnancy  renders  the  mother  more  liable  to  the  infection  of  small- 
pox, in  those  cases  in  which  variola  occurs  in  women  who  have  formerly 
been  vaccinated  the  disease  runs  a  comparatively  mild  and  favorable  course. 
\Taceination  should  be  performed  unhesitatingly  during  pregnancy  whenever 
variola  is  epidemic.  Especial  care  should  be  exercised  in  procuring  pure 
virus,  and  antiseptic  precautions  are  necessary  in  performing  the  vaccination. 
There  is  abundant  reason  to  believe  that  the  fetus  is  protected  by  such 
vaccination. 

Pneumonia  occurring  during  pregnancy  is  a  serious  complication  for 
mother  and  child.  The  interference  with  respiration  occasioned  by  the  size 
of  the  pregnant  uterus,  and  the  unfavorable  conditions  under  which  the 
heart  labors  during  pregnancy  account  in  large  part  for  the  severity  of  the 
complication.  Jurgensen,  among  2475  women  suffering  from  pneumonia, 
found  43  who  were  pregnant.  Of  this  number  more  than  half  aborted. 
As  in  the  other  infections,  the  degree  of  fever  present  is  of  great  importance 
in  prognosis. 

The  symptomatology  of  pneumonia  in  the  pregnant  does  not  differ  from 
that  of  the  disorder  in  the  non-pregnant.  It  is  observed,  however,  in  preg- 
nant patients  that  embarrassment  of  the  circulation  is  very  often  pi'esent, 
and  that  heart  failure  develops  more  rapidly  than  in  the  non-pregnant. 
Mann370  reports  the  case  of  a  woman,  aged  forty-two,  with  typical  pneu- 
monia at  eight  months'  pregnancy.  The  fetal  heart-sounds  ceased  five  days 
after  the  initial  chill.     Shortly  after  the  crisis  of  the  pneumonia  the  woman 

19 


290  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

was  delivered  with  the  aid  of  forceps.  During  labor  the  patient  became 
cyanotic,  and  she  was  allowed  to  bleed  freely  from  the  umbilical  cord; 
although  an  unfavorable  prognosis  had  been  given,  the  patient  made  an 
uninterrupted  recovery.  In  this  connection  the  writer  reports  the  case  of  a 
young  primigravida,  aged  twenty,  who  developed  pneumonia  when  near  the 
end  of  gestation.  A  temperature  of  103°  F.  rapidly  developed,  and  an 
acute  pneumonic  process,  catarrhal  in  nature,  was  found  over  both  lungs. 
The  patient's  distress  and  dyspnea  steadily  increased,  and  three  days  after 
the  beginning  of  the  pneumonia  the  child  was  expelled  with  three  or  four 
severe  labor  pains.  The  child  was  cyanosed,  had  fever,  and  after  passing 
through  an  attack  of  pneumonia  recovered.  (Plates  20,  21.)  Although  the 
mother's  urgent  symptoms  were  relieved  temporarily  by  labor,  she  perished 
of  heart  failure  soon  afterward.  Examination  of  her  urine  during  the  pneu- 
monia and  before  her  delivery  showed  the  presence  of  albumin  in  appre- 
ciable quantity,  and  the  proportion  of  urea  was  1.2  per  cent.  Epithelium 
from  the  kidneys,  with  abundant  crystals  of  oxalate  of  lime,  was  found  on 
microscopical  examination.  The  urine  contained  large  quantities  of  bacteria 
of  various  kinds. 

The  treatment  of  pneumonia  complicating  pregnancy  is  similar  to  that  of 
pneumonia  in  the  non-pregnant.  The  patient's  condition  is  in  no  way 
improved  by  the  induction  of  labor,  and  the  occurrence  of  labor  should 
often  be  made  the  occasion  for  depleting  the  circulation  through  controllable 
postpartum  hemorrhage.  Pneumonia  complicating  pregnancy  offers  more 
opportunities  for  depletion  than  does  pneumonia  in  the  non-pregnant  woman, 
and  symptoms  of  threatened  asphyxia  with  profound  cyanosis  should  be  met 
promptly  by  this  resource.  Cupping  gives  great  relief  in  these  cases,  and 
the  hypodermic  use  of  strychnin  and  atropin  has  proved  of  comfort  to  the 
patient.  The  complication  is  serious  in  proportion  to  the  extent  of  lung 
tissue  involved  and  the  tolerance  or  intolerance  displayed  by  the  circulatory 
apparatus. 

The  jwognosis  of  pneumonia  occurring  during  pregnancy  has  been  made 
the  subject  of  study  by  Wallich,371  who  found  that  pneumonia  interrupts 
pregnancy  in  one-third  of  all  cases  before  the  sixth  month,  and  from  the 
sixth  to  the  ninth  month  in  two-thirds  of  all  cases.  The  maternal  mortality 
varied  from  50  to  100  per  cent,  of  recorded  cases,  whereas  the  fetal  mor- 
tality was  80  per  cent. 

Cholera  occurring  during  pregnancy  well  illustrates  the  severity  of  a 
pronounced  infection  with  the  pregnant  patient.  From  a  series  of  10  cases 
Klautsch373  describes  two  stages  of  the  disease — one  attended  by  copious 
evacuations  from  the  stomach  and  intestines,  the  second  by  a  period  of 
intoxication  or  asphyxia.  The  patients  were  taken  ill  usually  at  midnight  or 
early  in  the  morning,  and  when  temporary  relief  from  the  symptoms  of  col- 
lapse had  been  obtained  by  the  injection  of  saline  fluids,  a  typhoidal  stage 
frequently  developed,  with  active  delirium,  followed  by  deepest  coma. 
During  the  coma  the  pulse  was  strong  and  dicrotic,  and  the  respiration  was 


PREGNANCY. 


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THE   PATHOLOGY    OF   PREGNANCY.  291 

irregular.  Hemorrhage  into  the  conjunctivae  was  often  present.  The 
fetus  usually  perished  in  these  cases  during  the  stage  of  intoxication.  In 
the  first  stage  of  the  disease  the  patients  complained  that  fetal  movements 
were  exceedingly  violent.  It  has  been  shown  by  Slaviansky,  Tipjakoff,  and 
Simmonds  that  the  epithelium  of  the  placenta  is  extensively  diseased,  and 
that  hemorrhages  and  premature  separation  often  occur.  In  cases  in  which 
the  fetus  died,  it  was  usually  expelled  at  the  end  of  the  stage  of  asphyxia 
and  in  the  beginning  of  the  typhoidal  delirium.  Instrumental  delivery  fre- 
quently was  necessary.  Postpartum  hemorrhage  rarely  was  observed,  and 
when  the  mother  survived,  involution  often  proceeded  promptly. 

The  prognosis  for  the  mother  was  as  favorable  as  the  prognosis  in  cholera 
in  non-pregnant  women.     For  the  fetus  the  prognosis  was  exceedingly  grave. 

The  treatment  of  pregnant  patients  attacked  by  cholera  is  the  treatment 
of  cholera  in  the  non-pregnant.  No  attention  should  be  paid  to  the  pregnant 
condition,  other  than  to  complete  labor  as  rapidly  as  possible  when  it  begins, 
and  to  secure  good  uterine  contractions  during  and  after  the  labor.  A  more 
unfavorable  view  of  the  prognosis  for  the  mother  is  given  by  Galliard.  In 
his  cases  the  lactic  acid  method  of  treatment  was  employed  extensively,  with 
negative  results.     In  mild  cases  a  number  of  his  patients  recovered. 

Tetanus  in  Pregnancy. — Among  the  acute  infections  that  attack  the 
nervous  system  of  the  pregnant  patient  with  great  virulence  tetanus  is  the 
most  formidable.  From  our  knowledge  of  infection  it  is  rendered  clear  that 
the  tetanus  bacillus  is  the  exciting  cause  of  this  complication.  A  predis- 
posing cause  is  to  be  found  in  the  susceptibility  that  pregnant  patients  mani- 
fest during  the  first  three  months  of  this  period.  Indeed,  the  first  half  of 
gestation  shows  by  far  the  greater  number  of  cases  of  this  infection.  Teta- 
nus develops  usually  after  some  minor  manipulation  in  the  early  months  of 
pregnancy,  and  especially  when  abortion  requires  interference  on  the  part  of 
the  physician.  Thus,  Vinay373  in  106  cases  found  but  1  after  craniotomy 
and  1  after  Cesarean  section.  The  infection  is  one  of  early  pregnancy,  and 
is  not  usually  connected  with  parturition  at  term.  Patients  most  likely  to 
be  attacked  by  the  tetanus  bacillus  are  multiparas  above  the  average  age, 
and  those  who  have  been  living  in  damp  and  squalid  lodgings.  The  direct 
conveyance  of  the  infection  has  been  noted  by  Henricius  and  by  Anion.  The 
latter,  while  treating  a  case  of  tetanus  in  the  husband,  infected  the  wife, 
who  had  aborted,  during  the  manual  delivery  of  the  placenta.  Tetanus  is 
most  frequent  among  pregnant  patients  in  the  tropics,  where  the  condition 
of  the  soil  is  favorable  to  the  growth  of  the  infecting  germ.  An  association 
of  tetanus  in  pregnancy  and  the  puerperal  period  with  endometritis  has  been 
pointed  out  by  Markus.374 

The  treatment  of  tetanus  in  pregnancy  is  largely  prophylactic.  Bearing 
in  mind  the  peculiar  susceptibility  of  pregnant  patients,  especially  during 
the  first  months,  any  minor  operation  or  examination  should  be  conducted 
with  scrupulous  antisepsis.  When  tetanus  infection  has  occurred,  but  little 
can  be  done  to  save  the  patient. 


292  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

Tetany  daring  pregnancy  is  a  condition  that  is  commoner  than  tetanus. 
It  is  characterized  by  tonic  spasms  beginning  in  the  muscles  of  the  extremi- 
ties, especially  those  of  the  hands.  In  severe  cases  spasmodic  movements 
may  extend  over  the  entire  muscular  system.  When  not  artificially  pro- 
duced, the  spasms  are  symmetrical.  Attacks  of  tetany  are  not  accompanied 
by  loss  of  consciousness.  Such  seizures  are  intermittent  and  of  short  dura- 
tion. As  a  rule,  recovery  ensues,  the  spasms  gradually  becoming  less  fre- 
quent. Patients  describe  a  tingling  or  a  numb  sensation  of  the  extremity 
affected  as  preceding  the  spasm,  and  the  same  sensation  follows  the  cessation 
of  convulsive  movements.  If  the  main  artery  or  the  nerve  of  the  extremity 
in  which  spasmodic  movements  are  observed  be  compressed,  these  sensations, 
followed  by  spasm,  may  be  induced.  The  application  of  cold  tends  to  check 
the  spasms  of  tetany.  The  flexor  muscles,  and  especially  the  interossei  in 
the  hands  and  feet,  are  oftenest  affected.  The  electrical  reaction  of  the 
nerves  in  the  affected  region  is  much  increased.  The  patient's  general  tem- 
perature is  not  affected.  Any  mechanical  irritation  of  the  peripheral  nerves, 
such  as  tapping  the  trunk  of  the  facial  nerve  in  front  of  the  ear,  results  in 
spasm.  The  disorder  is  generally  sporadic  and  is  rarely  epidemic.  It  is 
most  usually  observed  in  women  during  the  child-bearing  period  or  during 
menstruation.  Of  44  cases,  Trousseau  found  40  among  nursing  women. 
Kussmaul  found  transient  albuminuria  present,  and  Stiel  observed  glyco- 
suria. Dakin375  reports  the  case  of  a  multigravida  of  nervous  temperament 
who,  in  the  third  month  of  her  fourth  gestation,  was  seized  with  frequent 
vomiting  during  the  day.  After  this  condition  had  persisted  for  eleven  days 
she  developed  spasm  of  various  muscles,  preceded  by  numbness.  The 
hands  and  feet  assumed  the  posture  seen  in  tetany — the  flexors  in  contraction, 
and  the  interossei  producing  extension  of  the  phalanges.  The  soles  of  the 
feet  were  hollowed  by  spasmodic  extension.  The  affected  muscles  were 
somewhat  painful.  The  condition  extended  to  all  the  extremities,  and 
vomiting  was  increased.  On  the  second  day  of  tetany  the  spasmodic  con- 
dition became  so  severe  as  to  give  rise  to  intense  suffering.  The  temperature 
was  subnormal.  The  patient  died  of  asphyxia,  produced  by  spasm  of  the 
muscles  of  respiration,  on  the  third  day  of  the  tetany.  Trousseau  recog- 
nizes o  varieties  of  tetany,  in  accordance  with  the  severity  of  the  affection. 
He  rarely  observed  a  fatal  result.  Meincrt  saw  5  cases  end  in  recovery.  In 
1  of  these  cases  the  patient  suffered  from  tetany  in  successive  pregnancies. 
In  1  of  Meinert's  cases  the  thyroid  gland  was  removed.  Between  the 
attacks  of  tetany  the  patient  is  to  all  appearances  normal.  In  non-fatal 
cases  the  pregnancy  is  not  interrupted  nor  is  labor  influenced,  the  spasms 
ceasing  as  soon  as  the  uterus  is  emptied  or  within  a  few  days. 

In  differentiating  tetanus  from  tetany  in  pregnant  patients  it  is  well  to 
remember  that  in  tetanus  the  spasm  begins  in  the  face  or  the  neck  and 
advances  centrifugally,  with  opisthotonos.  In  tetany  the  spasm  begins  in 
the  extremity  and  advances  centripetally,  producing  the  characteristic  posture 
of  the  extremities.     In  tetanus  the  spasm  is  constant :  in  tetany  it  is  inter- 


THE   PATHOLOGY    OF  PREGNANCY.  293 

mittent.  The  great  fatality  of  tetanus  and  the  comparative  mildness  of 
tetany  are  to  be  kept  in  mind.  Tetanus  is  most  frequent  among  men,  who 
by  virtue  of  their  occupations  are  exposed  to  infection  from  the  tetanus 
bacillus.  Tetany  is  peculiarly  common  among  pregnant  "women  or  women  in 
a  depressed  and  susceptible  condition.  "With  accurate  observation  the  dif- 
ferential diagnosis  between  the  convulsions  of  toxemia  and  those  of  tetany  is 
not  difficult. 

The  treatment  of  tetany  in  pregnancy  consists  in  giving  the  patient  such 
sedatives  and  anodynes  as  shall  procure  sleep.  Vomiting  or  diarrhea 
requires  especial  attention,  as  these  induce  a  condition  of  debility  that  favors 
a  fatal  issue.  Abortion  should  not  be  induced  in  tetany,  as  the  disorder 
rarely  fails  to  yield  under  intelligent  medication. 

Thomas3713  reports  the  case  of  a  patient  seen  in  the  Johns  Hopkins  Hos- 
pital in  her  seventh  pregnancy.  The  attacks  of  tetany  began  in  the  second 
pregnancy  and  recurred  at  the  fifth  month  in  each  case.  They  were  ushered 
in  with  a  tired,  aching  sensation  in  the  hands,  the  fingers  later  becoming 
stiff  and  clenched,  the  feet  also  being  stiff  and  drawn.  In  severe  attacks  the 
pain  was  intense,  and  the  fingers  were  so  tightly  closed  that  the  nails  cut 
through  the  skin,  the  arms  being  stiff  and  held  close  to  the  chest,  and  the 
hands  blue  and  swollen.  Other  muscles  of  the  body  were  also  involved  at 
times.  The  nerves  responded  with  unusual  readiness  to  both  electric  cur- 
rents, and  the  deep  reflexes  were  exaggerated.  The  disease  had  lasted 
twelve  years,  during  the  second  half  of  her  pregnancies.  The  patient  was 
free  while  nursing  a  child,  but  when  menstruation  reappeared,  the  disease 
returned.  Thomas  has  collected  32  cases  hitherto  reported.  Certain  poisons, 
such  as  chloroform  and  alcohol,  have  been  said  to  cause  the  disorder,  and 
the  removal  of  the  thyroid  gland  may  produce  it.  Child-bearing  is  known 
to  favor  its  occurrence.  In  Weiss'  case  a  goiter  was  removed  entire  from  a 
woman  four  months  pregnant,  and  immediately  after  the  operation  tetany 
appeared.  In  Gottstein's  case  tetany  developed  during  pregnancy  and  was 
accompanied  by  hypertrophy  of  the  thyroid  gland.  This  patient  improved 
greatly  on  transplantation  of  the  thyroid  and  on  the  administration  of 
thyroid  extract. 

4.  Accidents  and  Surgical  Operations  During  Pregnancy. 

Although  the  nervous  system  of  the  pregnant  woman  is  remarkably  sus- 
ceptible in  many  ways  to  reflexes,  there  is  sometimes  exhibited  a  very  decided 
power  of  tolerance  to  severe  injury  or  surgical  interference.  The  variability 
of  this  resisting  power — some  patients  showing  a  remarkable  tolerance, 
whereas  others  display  but  a  feeble  power  of  resistance — depends  not  only 
upon  the  condition  of  the  nervous  system  in  these  cases,  but  also  upon  the 
normal  or  abnormal  state  of  the  uterus  and  its  lining  membrane.  In  a 
woman  in  perfect  health  a  quite  severe  injury  or  a  surgical  shock  may  be 
received  without  interrupting  pregnancy,  whereas  if  the  patient  possesses 
an  extraordinarily  susceptible  nervous  system  or  if  the  endometrium  is  in  a 


294  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

diseased  condition,  interruption  is  almost  inevitable.  Accompanying  the 
premature  termination  of  gestation  serious  hemorrhage,  shock,  and  greatly 
increased  susceptibility  to  septic  infection  are  observed. 

Those  operations  most  frequently  demanded  during  pregnancy  are  surgical 
procedures  undertaken  for  some  condition  of  the  uterus  or  of  its  appendages. 
Thus,  carcinoma  of  the  uterus  demands  the  complete  extirpation  of  that 
organ  as  soon  as  the  diagnosis  is  made,  irrespective  of  the  existence  or  the 
period  of  gestation.  One  of  two  methods  of  operation  may  be  chosen — 
extirpation  through  the  vagina  when  the  diseased  uterus  is  small,  or  the  com- 
plete removal  of  that  organ  through  the  abdominal  cavity  when  its  size  pre- 
cludes the  possibility  of  its  removal  through  the  vagina.  In  either  instance 
the  prognosis  for  the  recovery  of  the  mother  is  by  no  means  hopeless  if  the 
operation  be  performed  before  her  strength  has  been  reduced  by  the  develop- 
ment of  cancerous  cachexia.  It  is  sometimes  possible  to  combine  the  two 
methods  of  operation,  as  was  done  in  an  interesting  case  reported  by  Stocker,377 
in  which  a  multigravida  was  found  to  have  cancer  of  the  cervix.  At  the 
sixth  month  of  pregnancy  the  cervix  was  removed  through  the  vagina,  and 
complete  extirpation  of  the  uterus  was  accomplished  by  opening  the  abdom- 
inal cavity.     The  patient  made  a  good  recovery  from  the  operation. 

Myomotomy  and  myomectomy  during  pregnancy  are  demanded  for 
fibroid  tumors  complicating  the  development  of  the  pregnant  uterus.  The 
choice  of  operation  will  depend  upon  the  size  and  location  of  the  tumor,  and 
upon  the  amount  of  pressure  that  it  exercises  or  that  it  will  cause  upon  the 
growing  uterus.  Flaischlen 37S  found  2  fibroid  tumors  behind  the  uterus  in 
the  case  of  a  patient  three  months  pregnant :  one  tumor  sprang  from  the 
cornu  of  the  uterus,  the  other  from  the  base.  Both  tumors  were  ligated  and 
removed  without  interruption  of  pregnancy. 

The  influence  of  myomatous  tumors  upon  pregnancy  has  been  thoroughly 
reviewed  in  Hofmeier's  paper.379  He  finds  sterility  present  in  10.8  per  cent, 
of  those  having  such  tumors.  He  believes  that  sterility  in  such  patients 
very  often  is  not  clue  to  the  presence  of  a  fibroid.  He  tabulates  19  cases  of 
fibroid  complicating  pregnancy,  and  gives  the  results  of  their  treatment.  In 
general,  he  does  not  find  the  high  percentage  of  complications  present  in  these 
cases  that  some  have  reported.  In  choosing  a  method  of  treatment  in  labor 
complicated  by  fibroid  tumor  Pobedinsky 3S0  carried  out  an  interesting  proce- 
dure in  the  clinic  at  Moscow.  The  patient  was  a  multipara  in  labor  •who  had 
a  fibroid  tumor  developed  in  one  of  the  broad  ligaments.  The  child  was 
alive  and  in  good  condition.  The  prospect  for  preservation  of  the  child,  the 
removal  of  the  tumor,  and  the  preservation  of  the  uterus  seemed  favorable. 
Accordingly,  abdominal  section  was  performed,  the  child  and  its  appendages 
were  extracted,  and  the  tumor  was  then  removed  from  the  broad  ligament. 
The  parts  were  joined  by  deep  sutures,  and  the  uterus  was  closed.  The 
patient  made  a  good  recovery,  complicated  by  infiltration  of  the  broad  liga- 
ment from  which  the  tumor  had  been  removed.  This  gradually  disappeared. 
Leopold 3S1  reports  a  case   of  pregnancy  complicated  by  myoma  in   the 


THE   PATHOLOGY   OF  PREGNANCY.  295 

anterior  wall  of  the  uterus.  Abdominal  incision  was  performed,  and  a  some- 
what calcified  tumor  was  removed.  This  was  followed  by  considerable  hem- 
orrhage, which  was  checked  by  incising  a  portion  of  the  capsule  and  packing 
the  cavity  with  iodoform  gauze.  Twenty-six  deep  and  superficial  catgut 
sutures  were  required  to  close  the  bed  of  the  tumor.  Pregnancy  continued, 
and  the  patient  was  subsequently  delivered  at  full  term  in  normal  labor. 
Leopold  adds  a  table  of  31  cases,  with  the  results  in  each.  When  multiple 
myomata  are  present  and  the  uterine  wall  is  extensively  changed,  it  is 
impossible  to  preserve  the  uterus,  and  incision  into  the  uterine  wall  may  be 
followed  by  considerable  hemorrhage.  Pagenstecher 332  reports  the  case  of  a 
primigravida  who  had  multiple  myomatous  tumors.  The  effort  to  remove 
one  that  had  a  pedicle  was  followed  by  rupture  of  the  substance  of  the 
uterus  with  free  hemorrhage.  It  was  necessary  to  remove  the  uterus,  leaving 
a  stump  of  cervix  that  was  freely  cauterized.  The  patient  made  a  good 
recovery.  On  examining  the  tissue  removed  multiple  myomata  were  present, 
together  with  an  embryo  of  six  weeks.  The  disadvantage  of  treating  a 
pedicle  outside  the  peritoneum  is  exemplified  in  a  case  reported  by  Werder.383 
He  had  removed  a  subperitoneal  uterine  fibroid  with  a  short,  thick  pedicle  by 
the  extraperitoneal  application  of  the  elastic  ligature.  A  sinus  remained 
at  the  lower  angle  of  the  abdominal  wound.  Pregnancy  occurred,  and  at 
the  end  of  the  fourth  month  hemorrhage  took  place  through  the  abdominal 
fistula,  which  had  become  considerably  larger.  This  recurred  at  irregular 
intervals,  causing  anemia.  Labor  was  three  weeks  premature,  and  a  living 
but  poorly  developed  child  was  delivered  by  forceps.  The  placenta  was 
adherent  immediately  under  the  abdominal  fistula  and  required  manual 
separation.  The  patient  recovered.  The  abdominal  fistula  closed  very 
slowly,  and  on  several  occasions  menstruation  occurred  through  the  fistula. 

Amputation  of  the  pregnant  uterus  is  an  operation  performed  in  con- 
tracted pelvis.  It  may  be  performed  at  any  period  of  gestation  when  the 
interests  of  the  patient  demand  hysterectomy.  The  method  of  procedure 
best  adapted  to  such  cases  is  abdominal  incision,  ligation  of  the  ovarian  and 
uterine  arteries,  and  amputation  of  the  uterus,  leaving  a  short  stump  to  close 
the  vagina,  and  stitching  the  peritoneum  over  the  surface  of  the  stump. 

Tumors  of  the  ovary  are  justly  considered  serious  complications  of 
pregnancy.  Dsirne384  collected  135  cases  in  which  pregnancy  was  compli- 
cated by  tumor  of  the  ovary.  He  finds  that  the  gravity  of  this  complica- 
tion disappears  as  pregnancy  advances.  In  this  complication  there  is  rarely 
any  reason  for  delay  in  removing  such  a  tumor  by  abdominal  incision. 
Puncture  of  an  ovarian  cyst  and  the  artificial  interruption  of  pregnancy  are 
to  be  avoided  :  they  are  to  be  considered  only  in  the  light  of  procedures 
adapted  to  an  unforeseen  emergency.  The  preferable  time  for  operation  in 
such  cases  is  before  the  fourth  month  of  gestation.  The  fetus  is  less  likely 
to  be  lost  when  operation  is  performed  in  the  third  or  the  fourth  month.  This 
complication  demands  operative  treatment,  and  no  period  of  pregnancy 
contraindicates  ovariotomy.     Double  ovariotomy  during  pregnancy  may  be 


296  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

performed  successfully,  as  exemplified  by  Polaillon.385  His  patient,  aged 
twenty-three,  had  a  large  ovarian  cyst  upon  one  side  and  a  diseased  ovary 
upon  the  other.  Her  general  condition  at  the  time  of  operation  was  not 
promising,  and  numerous  adhesions  complicated  the  removal  of  the  tumor. 
Operation  was  performed  in  the  third  month  of  gestation.  Pregnancy  con- 
tinued, and  terminated  in  normal  delivery  with  a  healthy  child.  The  patient's 
pulse  and  temperature  showed  little  reaction  following  operation.  Kreutz- 
man  3S6  reports  2  cases  in  which  ovarian  tumors  were  successfully  removed 
from  pregnant  patients  without  interrupting  gestation.  One  of  these  women, 
who  was  in  her  second  pregnancy,  had  gone  two  weeks  over  time.  She  had 
a  laroe  cyst  in  the  left  ovary,  the  pedicle  of  which  had  recently  become 
twisted,  the  contents  of  the  tumor  being  tinged  with  blood. 

The  theory  that  advocates  removal  of  tumors  of  the  ovary  during  preg- 
nancy as  soon  as  their  presence  is  ascertained  has  much  to  commend  it. 
Isirne3S7  has  collected  23  operations  without  a  death.  The  prognosis  is  best 
for  the  mother  in  the  second,  third,  and  fourth  months  of  gestation,  and  for 
the  child  in  the  third  and  fourth  months.  The  dangers  that  pregnancy  adds 
to  the  presence  of  the  tumor  are  rapid  growth  and  torsion  of  the  pedicle. 
Kreutzmann388  removed,  at  the  second  month  of  pregnancy,  a  multilocular 
ovarian  cyst  of  the  left  side  whose  pedicle  was  twisted  about  half  from  out- 
side to  inside.  This  condition  had  evinced  no  symptoms  and  was  not  diag- 
nosticated before  the  operation.  Had  the  tumor  been  allowed  to  remain  as 
pregnancy  continued,  gangrene  of  the  cyst  must  have  supervened. 

That  tapping  is  one  of  the  worst  methods  of  treatment  is  well  illustrated 
by  a  case  reported  by  King.3*9  The  patient  had  been  in  labor  for  some  time, 
and  the  pelvis  was  filled  by  a  tumor  that  prevented  the  descent  of  the  head. 
The  tumor  was  punctured  through  the  rectum  ;  fluid  escaped,  and  a  dead 
child  was  spontaneously  expelled.  The  patient  made  an  apparent  recovery. 
Six  weeks  after  parturition  she  was  again  admitted  to  the  hospital  with  a 
large  abdominal  tumor.  Fever  and  emaciation  were  present,  and  the  diag- 
nosis of  pulmonary  disease  had  been  made.  During  the  examination  the 
tumor  burst  into  the  rectum,  and  about  a  gallon  of  offensive  yellow  pus  was 
removed.  The  cavity  w-as  drained,  and  the  patient  recovered.  The  tumor 
undoubtedly  became  infected  at  the  time  of  the  rectal  puncture,  and  the 
patient's  recovery  is  remarkable.  This  case  is  in  distinct  contrast  to  the 
excellent  results  of  abdominal  section  with  entire  removal  of  the  tumor. 

That  an  ovarian  tumor  may  contain  the  encysted  remains  of  tubal  gesta- 
tion is  illustrated  by  Rosenwasser's  case.390  This  patient  had  had  a  ruptured 
ectopic  gestation  with  hematoma,  and,  in  addition,  a  tumor  that  distended  the 
rectovaginal  pouch,  and  was  found  upon  aspiration  to  be  an  ovarian  cyst. 
On  abdominal  section  the  tumor  was  removed  and  also  the  contents,  the 
ectopic  fetus.     The  patient  made  an  excellent  recovery. 

Affections  of  the  Fallopian  tubes  may  call  for  operative  interference 
during  pregnancy.  The  prognosis  in  these  cases  is  equally  as  good  as  that 
of  operation  for  the  removal  of  ovarian  tumors,  and  the  reasons  for  prompt 


THE   PATHOLOGY    OF  PREGNANCY.  297 

interference  are  quite  as  cogent.  In  hematosalpinx  it  is  often  impossible  to 
make  a  differential  diagnosis  between  this  condition  and  ectopic  gestation.  This 
fact  is  well  illustrated  in  the  exjjerience  of  Doran,391  who  removed  both 
tubes  and  ovaries  from  a  patient  who  had  suffered  from  attacks  of  violent 
pelvic  pain  at  various  intervals.  One  tube  had  ruptured,  allowing  the  free 
escape  of  blood  ;  the  tube  contained  a  structure  in  the  midst  of  a  clot  resem- 
bling an  aborted  ovum.  It  is  probable  that  double  ectopic  gestation  existed. 
The  patient  made  an  uninterrupted  recovery. 

Accidents  and  Injuries. — As  regards  tolerance  to  general  accidents  and 
injuries  during  pregnancy,  American  observers  have  noted  the  remarkable 
tolerance  displayed  by  negro  women  under  such  circumstances.  Thus  Tif- 
fany 392  reports  the  case  of  a  negro  woman  who  fell,  striking  the  abdomen 
violently  against  the  edge  of  a  tub.  Peritonitis  with  retention  of  urine  fol- 
lowed. With  careful  treatment,  however,  the  patient  recovered  without  the 
interruption  of  pregnancy.  Stab-wounds  of  the  abdomen  occurring  during 
the  pregnant  period,  but  without  interrupting  gestation,  are  reported  by 
Belin,393  in  whose  patient  a  considerable  portion  of  the  epiploon  protruded 
from  the  wound.  Sloughing  ensued,  but  the  patient  made  a  good  recovery. 
Richard m  describes  the  case  of  a  pregnant  woman  who  fell,  lacerating  the 
abdominal  wall  near  the  umbilicus.  A  mass  of  intestine  as  large  as  a  man's 
head  protruded.  The  woman  was  at  term,  and  normal  labor,  from  which 
the  patient  recovered,  ensued  soon  after.  Harris395  describes  the  case  of  a 
woman  six  months  pregnant  whose  abdomen  was  torn  open  by  the  horn  of  a 
bull.  Although  omentum  and  intestine  protruded,  pregnancy  was  uninter- 
rupted. The  viscera  were  replaced,  and  the  wound  was  closed  by  suture. 
A  similar  case  in  which  a  lacerated  wound  of  the  abdominal  wall  5  inches 
long  was  made  is  reported  by  Corey.396  In  this  case  the  pregnancy  had 
reached  the  third  month.  The  patient  went  two  hundred  and  two  days 
longer  and  had  a  normal  labor.  Obstruction  of  the  intestine  demanding 
abdominal  section  is  described  by  Rydygier,397  who  operated  upon  a  patient 
in  the  sixth  month  of  gestation  who  showed  symptoms  of  strangulation  for 
seven  days.     Recovery  ensued  without  abortion. 

In  fractures  in  pregnant  women  retarded  union  is  reported  by  Petit 39S  and 
others. 

An  interesting  operation  for  stone  in  the  bladder  upon  a  patient  eight 
months  pregnant  is  reported  by  Keelan.399  The  calculus,  which  weighed 
12J-  ounces,  was  successfully  removed  without  the  interruption  of  pregnancy. 

Gunshot  wounds  not  penetrating  the  uterus  do  not  commonly  interrupt 
gestation.  A  remarkable  instance  is  cited  by  Prozowsky.400  The  patient 
was  wounded  in  many  places  by  pieces  of  lead  pipe  fired  from  a  gun  but  a 
few  feet  distant.  So  far  as  gestation  was  concerned,  neither  she  nor  her 
child  suffered  from  the  accident.  A  pistol-shot  wound  of  the  lung  occurring 
during  pregnancy,  followed  by  hemorrhage  and  shock,  is  reported  by  Ban- 
croft.401    A  healthy  child  was  born  at  term. 

A  remarkable  case  is  described  by  Lihotzky,402  which  illustrates  the  fact 


298  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

that  the  changes  occurring  in  pregnancy  may  bring  into  active  irritation  a 
foreign  body  that  had  previously  been  inert;  he  describes  the  case  of  a 
patient  perishing  from  rapid  peritonitis  in  the  eighth  month  of  pregnancy. 
At  the  autopsy  the  duodenum  was  found  perforated  by  a  spoon  that  the 
patient  had  swallowed  two  and  a  half  years  previously — an  occurrence 
almost  forgotten. 

The  remarkable  tolerance  shown  by  the  pregnant  woman  to  direct  injury 
from  mechanical  causes  is  illustrated  in  a  case  reported  by  Milner.403  The 
woman,  who  was  in  the  sixth  month  of  pregnane}',  was  accidentally  shot 
through  the  abdominal  cavity  and  the  lower  part  of  the  thorax,  the  missile 
penetrating  the  central  tendon  of  the  diaphragm  and  lodging  in  the  lung. 
Localized  pneumonia  and  peritonitis  seemed  to  limit  the  injury,  the  wound 
draining  through  the  lungs  by  very  free  expectoration.  Recovery  ensued, 
the  patient  giving  birth  to  a  healthy  child  sixteen  weeks  later. 

Direct  mechanical  injury  may  rupture  the  pregnant  uterus,  usually  result- 
ing in  the  death  of  the  patient.  It  is  interesting  to  observe  that  the  mem- 
branes may  remain  unruptured  in  these  cases,  thus  obscuring  the  diagnosis 
of  rupture  of  the  uterus.  Neugebauer 404  describes  a  case  of  suicide  in  which 
a  primigravida  threw  herself  from  the  third  story  of  a  house  upon  a  stone 
pavement  ;  the  immediate  cause  of  death  was  fracture  of  the  skull.  The 
uterus  ruptured,  and  the  fetus  in  its  unbroken  membranes  was  found  among 
the  mother's  intestines.     The  patient's  pelvis  also  sustained  serious  injury. 

That  pregnant  women  can  sustain  terrible  injury  complicated  by  erysip- 
elas and  still  go  on  to  term  is  illustrated  by  a  case  reported  in  the  Prager 
medic inische  Wochenschrift,  1881,  No.  6.  A  woman  in  the  eighth  month  of 
pregnancy,  while  working  in  a  brickyard,  was  buried  beneath  a  mass  of 
earth  and  rock.  A  terrible  gash  was  cut  through  the  scalp,  and  many , 
bruises  and  lacerated  wounds  were  sustained.  Erysipelas  attacked  the 
wounds  of  the  scalp,  and  the  patient  was  very  ill  for  a  time.  She  did  not, 
however,  miscarry,  but  bore  a  healthy  child  at  term.  Fancon  40S  describes 
the  case  of  a  woman  who  sustained  an  injury  to  the  knee  requiring  drainage. 
She  was  attacked  by  erysipelas,  which  spread  over  the  entire  body  save  the 
genital  organs  and  the  head  and  neck.  Pregnancy  was  uninterrupted  and 
recovery  ensued. 

Operations  upon  the  rectum  in  pregnant  patients  are  to  be  avoided  if 
possible.  It  has  been  shown  by  Tiffany i0b  that  such  operations  are  usually 
followed  by  abortion  or  miscarriage.  On  the  contrary,  as  shown  by  Tiffany,407 
a  diseased  kidney  may  be  removed  from  a  pregnant  patient  with  complete 
success. 

Whereas  major  operations  seem  to  be  well  borne  by  pregnant  women, 
minor  surgical  procedures  of  an  irritant  character  are  sometimes  attended 
by  disastrous  results.  Thus,  Fancon  observed  in  the  clinic  at  Strasburg  a 
case  in  which  cauterization  over  the  ankle-joint  was  practised  for  a  neglected 
sprain.  Abortion  followed,  complicated  by  septic  infection  necessitating 
amputation.     The  patient  finally  succumbed.     Pregnant  women  often  sur- 


THE   PATHOLOGY   OF  PREGNANCY.  299 

vive  burns  without  the  interruption  of  gestation  if  the  pregnancy  is  not  far 
advanced  and  the  burn  is  not  severe.  Hunt408  reports  a  case  of  extensive 
burn  in  the  ninth  month  of  pregnancy  that  seems  to  have  affected  the  fetus 
directly,  for  the  child  was  born  dead  and  blistered  over  an  area  corresponding 
with  the  burns  upon  its  mother's  body.  Curiously  enough,  cases  are  reported 
in  which  pregnant  women  have  suffered  from  abscess  of  the  breast,  the 
abscess  being  opened,  curetted,  and  drained  without  interrupting  pregnancy, 
although  interfering  with  the  breasts  usually  results  in  profound  disturbance 
of  the  uterus.  Pregnancy  is  no  contraindication  to  excision  of  the  cancerous 
breast,  as  illustrated  in  a  case  reported  by  Pilcher.409  Parasitic  growths  of 
the  abdominal  cavity  requiring  abdominal  section  have  been  treated  by  sur- 
gical interference  during  pregnancy  with  success.  Amputation  for  crushing 
injury  and  severe  blows  has  been  borne  by  pregnant  patients  and  recovery 
has  ensued.  A  remarkable  case  is  reported  by  Fancon,  in  which  a  pregnant 
woman  jumped  from  a  second-story  window  without  interrupting  the  gesta- 
tion. Amputation  at  the  hip-joint  during  pregnancy  has  been  successfully 
performed  by  Keen.410  The  operation  was  performed  for  malignant  disease  of 
the  femur.  The  patient,  who  was  five  months  pregnant,  had  been  living 
in  the  tropics.  She  made  a  good  recovery  after  the  oj>eration,  having  no 
symptoms  of  abortion  during  her  convalescence. 

In  deciding  upon  operations  upon  pregnant  patients  care  should  be  taken 
that  the  various  excretory  organs  of  the  body  be  placed  in  the  best  possible 
condition.  All  unnecessary  shock  is  carefully  to  be  avoided,  as  is  also  hem- 
orrhage. Although  a  hemorrhage  does  not  seem  to  produce  abortion,  it  is 
dangerous,  because  it  renders  the  patient  more  susceptible  to  septic  infection. 
Fractures  unite  poorly  in  pregnant  patients,  and  the  application  of  cauter- 
izing agents  should  not  be  practised  during  pregnancy.  Major  operations 
on  the  abdominal  contents  are  especially  well  borne.  Pregnancy  does  not 
contraindicate  operation  for  diseased  conditions  of  the  uterus,  the  tubes,  or 
the  ovaries,  provided  the  fetal  sac  is  not  opened. 

A  striking  instance  of  the  benefit  that  pregnant  patients  sometimes 
receive  from  operative  interference  is  shown  by  those  cases  of  osteomalacia 
during  pregnancy  greatly  benefited  by  oSphorectomy.  A  good  example  of 
this  is  the  case  described  byRasch:411  the  patient,  a  multigravida,  aged 
forty-one  years,  suffered  from  osteomalacia,  which  continued  after  the  birth 
of  her  twins.  As  the  condition  continued  to  grow  worse,  the  tubes  and 
ovaries  were  removed,  when  the  patient  immediately  began  to  improve,  and 
was  subsecpiently  able  to  walk. 

The  almost  incredible  power  of  resistance  that  the  pregnant  uterus  dis- 
plays to  interference  is  well  illustrated  by  a  case  reported  by  Vickery  : 412 
this  patient  was  subjected  to  medication  and  operative  interference  to  empty 
the  uterus ;  it  was  supposed  that  incomplete  abortion  occurred,  and  her 
physician  curetted  the  uterus  and  applied  tincture  of  iodin,  followed  by 
injections  of  hot  water.  Notwithstanding  this  treatment  pregnancy  con- 
tinued. 


300  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

The  prognosis  of  pregnancy  complicated  by  tumors  in  cases  subjected  to 
operation  must  be  considered  as  decidedly  favorable.  Gerdes413  gives  an 
interesting  account  of  16  cases  of  pregnancy  complicated  by  abdominal 
tumors;  out  of  the  16  cases  4  perished.  All  the  cases  were  treated  by 
operation,  many  of  them  in  the  most  radical  manner. 

5.  Diseases  of  the  Ovum. 
A.  Amnion. 

Hydramnios  (Hvdramnion;  Polyhydramnios;  Dropsy  of  the  Amnion). 
— This  is  the  condition  in  which  the  liquor  amnii  is  in  excess  of  the  normal 
quantity,  which  at  the  end  of  pregnancy  averages  between  one  and  two  pints. 
The  range  of  variation  is  considerable,  and  it  is  impossible  to  state  definitely 
the  frequency  of  moderate  degrees  of  increase,  especially  in  advanced  gesta- 
tion. Neither  can  it  be  stated  how  much  fluid  is  necessary  to  produce  well- 
marked  disturbances.  Undoubtedly  the  uterus  and  abdomen  will  tolerate  in 
one  woman  what  could  not  be  borne  without  marked  disturbance  in  another. 
The  amount  of  fluid  noted  in  different  cases  varies  from  two  to  twenty-five 
quarts. 

Associations. — Hydramnios  is  more  frequent  in  multipara?  than  in  primi- 
parse.  It  often  occurs  in  twin  pregnancies,  especially  those  of  uniovular 
development.  It  has  been  found  in  anemic  and  weakly  women ;  in  those 
with  dropsical  conditions ;  in  tuberculosis,  diabetes,  and  syphilis  (Winckel). 
In  a  number  of  instances  diseases  of  the  placenta  and  membranes  have  been 
described  ;  in  some  cases,  edema  of  cord  and  placenta. 

Frequently  fetal  anasarca,  ascites,  anencephalus,  or  spina  bifida  is  present. 
It  is  important,  however,  to  note  that  in  a  large  number  of  cases  (44  per 
cent.,  according  to  Bar)  no  maternal  or  fetal  peculiarity  can  be  found. 

Pathology. — The  origin  of  the  excessive  fluid  is  not  at  all  definitely 
known.  Theoretically  it  may  be  due  to  oversecretion,  imperfect  absorption, 
or  to  a  combination  of  these.  It  may  be  derived  from  maternal  or  fetal 
sources  or  from  both  combined.  That  the  normal  liquor  amnii  is  mainly  of 
maternal  origin  seems  now  well  established.  Zuntz'"  experiment  of  injecting 
sodium  sulphindigolate  into  the  veins  of  a  pregnant  rabbit,  producing  thereby 
blue  coloration  of  the  amniotic  fluid,  but  not  of  the  fetal  kidneys,  points 
strongly  in  this  direction.  The  contribution  of  the  fetal  kidneys  has  always 
been  believed  to  be  important,  but  Schaller's  experiments  greatly  discredit 
this  belief.  He  administered  phloridzin  to  pregnant  women  and  tested  the 
liquor  amnii  at  various  periods  for  sugar.  As  the  glycosuria  therebv  caused 
is  produced  mainly  in  the  kidneys,  it  was  possible  to  estimate  the  activity  of 
the  fetal  kidneys. 

These  results  were  as  follows  : 

1.  There  is  no  regular  secretion  and  periodic  excretion  of  urine  by  the 
fetus  even  at  the  end  of  pregnancy. 

2.  Fetal  renal  functional  activity  begins  only  when  the  process  of  labor 


THE   PATHOLOGY    OF  PREGNANCY.  301 

induces  changes  in  the  fetal  circulation.  Even  during  labor  it  is  exceptional 
that  the  fetus  urinates  into  the  amniotic  cavity. 

3.  The  fetal  kidneys  functionate  much  more  slowly  than  those  of  the 
adult. 

In  the  light  of  these  researches  it  is  extremely  probable  that  in  hydram- 
nios  the  increased  fluid  is  most  frequently  maternal  in  origin.  Certain  it 
is  that  dropsical  conditions  in  the  mother  are  apt  to  be  associated  with  excess. 
Fehling  has  noted  that  the  more  hydremic  the  maternal  blood,  the  more 
abundant  is  the  amniotic  fluid. 

Indeed,  it  is  not  improbable  that  an  important  factor  in  explaining  normal 
differences  in  the  quantity  of  liquor  amnii  in  pregnancy  is  a  variation  in  the 
hydremic  condition  of  the  maternal  blood. 

As  to  the  relative  influence  of  overproduction  and  deficient  absorption, 
nothing  can  be  said,  since  we  do  not  know  the  relationship  between  normal 
production  and  absorption. 

A.  R.  Simpson  thinks  that  another  important  factor  is  loss  of  tone  in  the 
uterine  wall.  This  suggestion  is  certainly  worthy  of  much  consideration  in 
view  of  the  frequency  of  hydramnios  in  multipara?,  especially  in  those  who 
have  borne  several  children,  and  in  multiple  pregnancies.  Many  believe 
that  the  increased  fluid  may  be  derived  from  the  following  sources  : 

(a)  Altered  States  of  the  Circulation. — Some  have  noted  the  persistence  of 
the  early  subamniotic  vasa  propria  of  Jungbluth  in  certain  cases  of  hydram- 
nios, and  have  believed  the  increased  fluid  to  have  arisen  by  exosmosis  from 
them.  This  is  altogether  unlikely,  because  in  most  cases  of  hydramnios 
no  such  vessels  are  found.  Then  it  is  known  that  vascularization  of  the  con- 
nective tissue  of  the  amnion  may  be  found  without  any  hydramnios. 

(6)  Others  believe  that  any  conditions  which  can  raise  blood-pressure  in 
the  umbilical  vein  and  vessels  of  the  villi  may  cause  hydramnios.  Thus,  it 
has  been  noted  in  some  cases  of  lesion  of  the  fetal  heart,  with  tumors  in  the 
fetus  obstructing  the  circulation,  in  abnormal  conditions  of  the  cord,  e.g., 
marked  torsion,  etc. 

Brindeau  has  reported  a  case  occurring  at  the  fifth  month  where  there  was 
sarcoma  of  one  fetal  kidney.  The  umbilical  vein  was  dilated,  and,  when 
fluid  was  injected  into  it,  transudation  was  observed ;  the  fetus  was  ascitic 
and  the  placenta  very  large.  It  is  to  be  noted,  however,  that  these  con- 
ditions often  exist  without  any  hydramnios ;  consequently  it  is  impossible  to 
have  any  accurate  knowledge  of  their  importance  as  causal  factors. 

(c)  Excessive  Fetal  Urination. — That  abnormal  activity  of  the  fetal  kid- 
neys may  sometimes  lead  to  hydramnios  is  possible,  though  in  no  way  proved. 
As  has  already  been  stated,  the  fetus  probably  does  not  normally  excrete 
urine  in  utero  until  the  process  of  labor  begins.  Why  this  function  should 
prematurely  develop  (if,  indeed,  it  does),  leading  to  an  excessive  quantity  of 
liquor  amnii,  is  altogether  uncertain. 

(d)  The  fetal  skin  may  occasionally  be  the  source  of  hydramnios.  This 
view  is  pure  hypothesis,  and  is  based  upon  the  very  rare  finding  of  hydram- 


302  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

nios  along  with  a  thickened  and  folded  condition  of  fetal  skin.  Budin  has 
also  noted  a  case  in  which  there  were  abundant  nevi.  These  fetal  changes 
may,  however,  have  been  in  no  way  connected  with  the  production  of  the  in- 
creased amniotic  fluid. 

(e)  Alterations  in  the  amnion  are  stated  to  be  an  occasional  cause.  Some 
think  that  inflammation  of  the  membrane  may  possibly  explain  the  produc- 
tion of  acute  hydramnios. 

A  few  observers  have  described  fissures  between  the  amniotic  cells  in  cer- 
tain cases,  through  which  they  believe  the  fluid  entered  the  amniotic  sac. 

The  relationship  to  twin  pregnancy  is  of  interest.  The  greater  fre- 
quency in  uniovular  development  has  been  noted.  Where  two  amniotic 
sacs  are  present,  there  is  usually  a  considerable  disproportion  in  the  sizes 
of  the  fetuses. 

Hydramnios  occurs  in  the  sac  containing  the  larger  fetus.  In  the  latter, 
hypertrophy  of  various  organs  may  often  be  found,  especially  in  the  heart; 
also  in  the  kidneys,  liver,  or  spleen.  It  is  believed  by  many  that  the  cardiac 
hypertrophy  causes  abnormal  activity  of  the  kidneys,  thus  leading  to  hy- 
dramnios ;  but  this  is  not  proved. 

Sometimes,  though  rarely,  both  amniotic  sacs  may  contain  an  excessive 
quantity,  even  though  one  fetus  is  not  much  larger  than  the  other.  Hydram- 
nios may  also  be  found  where  there  is  only  one  amniotic  sac. 

Physical  Signs  and  Symptoms. — The  disease,  rarely,  may  develop  rapidly. 
Usually  the  accumulation  of  fluid  takes  place  slowly.  In  the  great  majority 
of  cases  the  onset  is  noted  after  the  fifth  month. 

The  uterus  is  larger  than  it  is  at  the  corresponding  period  in  normal 
pregnancy,  and  generally  stands  at  a  higher  level.  Its  wall  is  tenser  than 
normal.  Fetal  parts  are  more  difficult  to  palpate,  and  the  heart  may  not  be 
so  often  found.     Fluctuation  is  usually  easily  obtained. 

It  is  of  great  importance  to  note  that  the  normal  variations  in  the  consist- 
ence of  the  uterine  wall  may  be  absent  for  long  periods.  Hardening  may 
not  be  felt  at  all  in  a  series  of  examinations  or  may  be  very  slightly  marked. 

In  acutely  developed  hydramnios  there  may  be  much  distress  and  pain  in 
the  abdomen.     Vomiting  and  other  reflex  disturbances  are  present. 

In  the  ordinary  chronic  case  marked  trouble  usually  develops  in  ad- 
vanced pregnancy,  though  there  are  many  variations  in  the  degree  to  which 
patients  may  be  affected.  There  are  gastro-intestinal  disorders,  difficulty  in 
respiration,  frequency  or  irregularity  of  cardiac  action  as  a  result  of  the  pres- 
sure of  the  large  uterus.  There  may  be  weakness  in  the  body  and  legs  and 
inability  to  move  about  with  ease.  Avarices  and  edema  of  the  lower  limbs, 
vulva,  and  abdominal  Avail  may  develop.  The  urine  may  become  scanty  and 
albuminous.     Ascites  may  develop. 

The  abdominal  wall  is  greatly  thinned  and  the  linea  alba  markedly 
stretched,  so  that  the  recti  are  widely  separated. 

Differential  Diagnosis. — In  the  early  months  the  condition  may  be  mis- 
taken for  pregnancy  with  hydatidiform  degeneration  of  the  chorion.     Flue- 


THE   PATHOLOGY    OF  PREGNANCY.  303 

tuation  is  not  present  in  the  latter  condition,  which  sooner  or  later  leads 
to  escape  of  blood  from  the  cervix  along  with  the  characteristic  vesicles. 
When  the  swelling  is  large,  the  condition  may  readily  be  mistaken  for  ovarian 
or  parovarian  tumor.  Repeated  examinations  should  be  made  in  order  to 
determine  especially  the  presence  of  a  fetus,  and  the  other  signs  of  preg- 
nancy. Ascitic  distention  of  the  abdomen,  especially  if  associated  with 
tubercular  or  malignant  masses,  may  simulate  hydramnios,  the  swellings 
sometimes  simulating  fetal  parts.  A  distended  bladder  along  with  pregnancy 
may  lead  to  a  diagnosis  of  hydramnios.  Twin  pregnancy  may  sometimes  be 
distinguished  with  difficulty  from  it. 

Prognosis. — In  about  50  per  cent,  of  cases  pregnancy  ends  prematurely. 
The  fetus  is  often  born  dead,  sometimes  shrivelled  or  macerated  or  mal- 
formed. Out  of  thirty-three  cases,  McClintock  noted  nine  dead-born  ;  of  the 
rest  which  were  born  alive,  ten  died  within  a  few  hours.  The  nature  of  the 
influence  of  hydramnios  on  the  fetus  is  not  known. 

Influence  on  Labor. — In  the  advanced  months  labor  is  usually  slow,  the 
pains  being  weak.  Malpresentations  and  malpositions  are  frequent.  Sudden 
escape  of  much  liquor  amnii  may  lead  to  complete  inertia  of  the  uterus. 
Rupture  of  the  uterus  has  been  noted  in  several  cases.  In  the  third  stage 
the  placenta  is  slow  in  being  expelled,  and  on  account  of  uterine  weakness, 
there  is  great  risk  of  hemorrhage.  The  danger  of  infection  is  also  greater 
than  in  a  normal  case. 

Treatment. — There  is  no  known  method  of  preventing  the  increase  of 
liquor  amnii.  In  cases  where  the  patient  is  fairly  comfortable  no  interference 
is  necessary.  A  well-fitting  binder  may  relieve  abdominal  distress  some- 
what. When  the  mother's  health  is  much  affected  in  marked  cases,  it  is 
advisable  to  draw  off  some  of  the  liquor  amnii  with  a  small  trocar,  the  mem- 
branes being  punctured,  if  possible,  above  the  level  of  the  os  internum. 
Rarely,  this  procedure  is  followed  by  improvement  without  the  occurrence 
of  premature  labor.  Generally,  however,  the  latter  is  induced.  The  via- 
bility of  the  fetus  is  not  to  be  considered  in  cases  where  the  mother's  condi- 
tion is  distressing. 

When  labor  takes  place,  the  mother  must  be  attended  with  great  care. 
When  dilatation  of  the  cervix  is  well  advanced,  a  quantity  of  amniotic  fluid 
should  be  drawn  off  slowly  with  a  fine  trocar.  If  dilatation  is  very  slow,  it 
may  be  promoted  by  artificial  means.  Delivery  of  the  child  by  forceps  or 
version  may  be  indicated.  In  the  third  stage,  artificial  removal  of  the 
placenta  may  be  necessary.  The  uterus  should  be  packed  with  gauze  for 
twenty-four  hours  to  stimulate  the  organ  and  to  prevent  bleeding,  and  large 
doses  of  ergot  may  be  administered. 

Oligohydramnios. — This  is  the  condition  in  which  there  is  a  deficient 
quantity  of  liquor  amnii.  Nothing  is  known  as  to  its  etiology.  A  few  cases 
have  been  described  in  which  oligohydramnios  in  late  pregnancy  has  been 
associated  with  absence  of  one  or  both  fetal  kidneys  or  with  imperforate 
urethra.    Gusserow  and  others  believe  that  such  cases  are  proof  that  the  fetal 


304  AMERICAN    TEXT- BOOK    OF    OBSTETRICS. 

kidneys  contribute  largely  to  the  liquor  amnii.  The  fetus  is  often  mal- 
formed as  a  result,  probably,  of  abnormal  pressure.  Imperfect  nutrition  of 
parts,  resulting  in  ulceration,  has  been  noted. 

Amniotic  Adhesions. — Bands  of  various  shapes  and  sizes  are  sometimes 
found,  passing  from  fetus  to  amnion,  generally  where  oligohydramnios  also 
exists.  They  are  non-vascular.  It  is  believed  that  they  arise  in  early 
embryonic  life,  as  a  result  of  deficiency  in  the  liquor  amnii,  the  surface  of 
the  fetus  being  thereby  allowed  to  come  into  contact  with  the  amnion,  union 
occurring  at  one  or  more  points.  As  the  ovum  develops,  the  joined  areas 
stretch.  Sometimes  the  bands  break  across,  remaining  attached  by  their 
ends  to  fetus  or  amnion.  They  may  cause  damage  to  the  fetus.  The  um- 
bilical cord  may  become  twisted  in  one  and  the  life  of  the  fetus  endangered. 
Parts  of  the  fetus  may  atrophy  from  constriction  by  a  band  ;  even  amputa- 
tion of  a  limb  may  be  brought  about.  Various  malformations  may  be 
produced — e.g.,  eventration,  anencephalus,  encephalocele,  etc.  Several  cases 
have  been  described  in  which  localized  destruction  of  the  skin  resulted  from 
the  traction  of  an  adhesion,  an  appearance  like  an  ulcer  being  produced.  The 
child  when  born  may  show  this  recently  formed  or  partly  cicatrized. 

Other  Variations  in  the  Liquor  Amnii. — The  fluid  varies  considerably  in 
color  and  consistence.  Early  it  is  usually  dull  grayish  white ;  in  the  late 
months  it  is  greenish,  the  wdiole  depending  upon  the  amount  of  meconium 
in  it.  In  consistence  it  may  be  limpid  and  thin,  or  thick  and  syrupy.  The 
odor  is  usually  only  slight,  but  it  may  sometimes  be  distinct  and  unpleasant. 
When  the  fetus  is  macerated  or  decomposition  has  set  in,  the  liquor  is  usually 
very  dark  colored  and  may  have  a  bad  odor. 

B.  Chorion. 

Hydatidiform  Degeneration  (Vesicular  Mole ;  Hydatid  Mole ;  Cystic 
Mole ;  Uterine  Hydatid  ;  Dropsy  of  the  Villi ;  Myxoma  Chorii  Multiplex). 
— This  condition  is  one  in  which  swellings  develop  on  the  chorionic  villi, 
varying  in  size  from  a  millet-seed  to  a  grape.  They  may  occur  at  the  ends 
of  the  villi,  or  several  enlargements  may  form  on  a  villus  resembling  a  chain 
of  beads.  Sometimes  the  swelling  is  elongated  and  bean-like,  a  considerable 
extent  of  villus  being  affected.  The  swelling  is  caused  by  a  localized  hyper- 
trophy of  the  normal  mucoid  tissue  which  forms  the  core  of  the  villus.  On 
microscopic  examination  the  outer  covering  shows  the  cells  of  the  Langhans 
layer  and  the  outer  layer  of  syncytium,  the  cells  being  thinner  and  more 
flattened  than  normal,  owing  to  stretching.  They  tend  to  be  separated  from 
one  another  and  in  large  swellings  may  disappear,  remains  of  the  syncytium 
onlv  being  left.  The  interior  consists  of  delicate  branching  mucoid  cells  and 
of  fluid  between  them,  the  relative  abundance  of  these  varying  in  different 
cases.  In  some  swellings  the  consistence  may  be  gelatinous ;  in  others 
watery,  a  cystic  condition  being  developed. 

The  fluid  contains  abundant  mucin  and  some  albumin.     It  is  generally 


THE   PATHOLOGY   OF  PREGNANCY. 


305 


pale  in  color,  but  sometimes  may  have  a  reddish  tinge,  due  to  the  presence 
of  blood. 

The  capillaries  of  the  villi  are  usually  obliterated.     The  swellings  on  the 
ends  of  the  villi  attached  to  the  decidua  extend  into  the  uterine  wall  as  they 


Decidual  cells 


Patch  of  decidua 
serotina. 


Fig.  149.— Fleshy  mole  (after  Fothergill).    Section  showing  the  uterine  surface  of  a  placenta  retained  five 
months.    Decidual  cells  are  seen  spreading  from  the  patch  of  original  decidua. 

enlarge  and  may  penetrate  its  entire  musculature.     Rarely,  the  peritoneal 
covering  may  be  perforated. 

Several  specimens  have  been  described  in  which  the  reflexa  was  perforated, 
the  swellings  lying  in  the  space  between  it  and  the  vera.     In  well-marked 


Fig.  150.— Fleshy  mole  (after  Fothergill).    a,  amniotic  surface  ;  b,  uterine  surface. 

cases  the  whole  mass  of  the  chorion  may  reach  the  size  of  a  cocoanut,  weigh- 
ing several  pounds.     Sometimes  hydramnios  is  also  present. 

The  disease  usually  begins  in  the  early  weeks  of  pregnancy.  It  may 
affect  both  chorion  frondosum  and  lseve,  in  part  or  entirely.  In  some  cases 
only  the  former  or  latter  may  be  affected  partially  or  completely.     The  ovum 


306  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

when  expelled  from  the  uterus  presents,  therefore,  different  appearances  in 
different  cases.  The  effect  on  the  embryo  also  varies  considerably.  If  the 
disease  be  extensive,  particularly  if  the  chorion  frondosum  be  affected,  the 
embryo  dies  and  disappears.  When  only  a  small  part  is  affected,  its  life  may 
not  be  endangered,  and  it  may  reach  full  time.  In  twin  pregnancy  the 
degeneration  may  be  present  in  one  ovum  and  absent  in  the  other. 

Etiology. — The  cause  of  the  condition  is  unknown.  There  is  no  proof 
whatever  of  the  view  held  by  many  that  it  is  due  to  endometritis.  Several 
cases  of  recurrence  in  the  same  women  have  been  reported. 

Results. — Early  expulsion  of  the  degenerated  ovum  may  occur,  usually 
between  the  third  and  sixth  months.  In  cases  where  the  fetus  has  not  been 
affected,  owing  to  the  small  amount  of  degeneration,  pregnancy  may  reach 
term. 

A  few  cases  have  been  reported  in  which  the  mole  has  not  been  expelled, 
even  where  the  embryo  has  disappeared,  but  has  remained  in  utero  several 
weeks  beyond  the  period  of  normal  pregnancy.  In  some  instances  it  has 
been  described  as  being  partially  expelled,  the  rest  remaining  in  the  uterus 
for  years.  In  some  cases  hemorrhage  may  be  so  excessive  as  to  endanger 
the  patient's  life ;  during  expulsion  of  a  mole  this  danger  is  great.  Occa- 
sionally the  contractile  power  of  the  uterus  may  be  considerably  weakened  ; 
intraperitoneal  bleeding  may  be  marked  as  a  result  of  perforation  of  its 
wall  by  the  mole. 

If  all  the  vesicles  are  not  expelled,  subinvolution  of  the  uterus  results, 
and  decomposition  may  take  place  in  the  portions  left  behind. 

In  recent  years  it  has  been  shown  by  different  workers  that  remains  of  a 
vesicular  mole  may  give  rise  to  one  form  of  the  disease  known  as  "  decidu- 
oma  malignum."  Metastatic  growths  tend  to  develop  in  the  vulva,  lungs, 
and  other  parts,  in  which  there  may  be  reproductions  of  the  molar  structure. 

Symptoms  and  Physical  Signs. — In  the  earlier  stage  there  is  no  indication 
of  the  change.  In  a  well-marked  case  it  is  usual  to  note  that  the  uterus 
increases  more  rapidly  than  in  normal  pregnancy.  Thus,  at  the  third  month 
the  organ  maybe  as  large  as  though  it  contained  a  fourth  or  fifth  month 
ovum.  Very  often  hemorrhage  occurs.  It  may  be  sudden  and  pi*ofuse,  or 
may  escape  in  driblets — either  as  pure  blood  or  as  serum.  When  intermittent, 
the  intervals  may  be  long  or  short. 

Occasionally  the  vesicular  masses  are  expelled  with  the  blood,  resembling 
"  white  currants  in  red  currant  juice."  As  a  result  of  the  loss  of  blood 
patients  often  become  very  much  debilitated.  When  rapid  increase  of  the 
uterus  takes  place,  excessive  vomiting  has  been  noted  in  a  few  cases. 

On  bimanual  examination,  when  the  condition  is  well  marked  the  uterus 
has  a  firm,  somewhat  doughy,  boggy  feeling,  its  outline  being  occasionally 
irregular.  Sometimes  the  cystic  masses  can  be  palpated  through  the  abdom- 
inal wall  or  rectum. 

The  usual  auscultatory  phenomena  of  pregnancy  are  generally  wanting. 
Ballottement  is  absent. 


THE   PATHOLOGY    OF  PREGNANCY.  307 

In  cases  where  the  mole  ceases  to  develop  and  is  not  expelled  from  the 
uterus,  the  latter  is  smaller  than  it  should  be  for  the  period  of  pregnancy 
represented.  Thus,  though  nine  months  have  elapsed  since  conception,  the 
uterus  may  only  be  as  high  as  the  umbilicus. 

Differential  Diagnosis. — The  diagnosis  may  be  very  difficult  in  some 
stages.  Thus  the  rapid  increase  in  size  may  simulate  hydramnios.  When 
early  hemorrhages  occur,  ordinary  abortion  may  be  suspected. 

Sometimes  vesicular  mole  is  mistaken  for  a  uterine  neoplasm.  When, 
after  hemorrhages,  expulsion  does  not  take  place,  the  diagnosis  of  missed 
abortion  may  be  made. 

It  is  interesting  to  note  that  true  hydatid  development,  due  to  the  echino- 
coccus,  may  very  rarely  be  found  in  utero.  Its  nature  is  characterized  by 
the  presence  of  echinococcus  heads  and  booklets. 

Treatment. — When  the  diagnosis  is  established,  the  uterus  should  be  emp- 
tied. This  is  best  carried  out  as  follows  :  If  the  cervix  is  patulous,  it  and 
the  vagina  should  be  firmly  tamponed  and  the  patient  placed  in  bed.  When 
the  cervix  is  closed,  it  should  be  partly  dilated  artificially,  in  order  that  the 
gauze  may  be  inserted.  If,  after  twelve  or  fourteen  hours,  the  mole  is 
expelled,  the  patient  should  be  anesthetized  and  the  uterine  cavity  carefully 
explored  with  one  or  two  fingers,  all  vesicles  remaining  in  it  being  carefully 
removed.  The  uterus  should  then  be  packed  for  twenty-four  hours.  If  the 
mole  be  not  expelled  by  uterine  efforts,  dilatation  of  the  cervix  should  be  car- 
ried out  and  the  mole  removed  with  the  fingers.  A  curet  is  inadvisable  on 
account  of  the  risk  of  perforating  the  uterine  wall  at  some  thinned  portion. 

When  vesicles  are  firmly  united  to  the  uterine  wall,  no  force  should  be  em- 
ployed in  trying  to  detach  them.  It  is  best  to  remove  those  which  easily 
come  away  and  to  curet  the  uterus  after  a  week  or  two. 

Myxoma  Diffusum. — Very  rarely  a  mucoid  hypertrophy  may  be  found 
in  that  portion  of  the  chorion  from  which  the  villi  spring.  It  maybe  spread 
over  a  large  area,  forming  a  gelatinous  layer,  under  the  amnion,  three  to  five 
millimeters  thick. 

Myxoma  Fibrosum. — Occasionally  a  fibroid  thickening  of  the  chorion  is 
found  either  in  the  subamniotic  layer  or  in  the  villi.  It  is  found  usually  in 
advanced  pregnancy. 

C.  Placenta. 

Anomalies. — At  term  the  shed  placenta  is  a  rounded  disc,  weighing 
about  a  pound.  Its  average  diameter  is  about  seven  inches ;  its  thickness 
varies  from  three-quarters  of  an  inch  to  an  inch,  being  greatest  near  the 
middle.  In  some  cases  the  thickness  is  fairly  even  in  all  parts  ;  in  others  it 
varies  considerably  in  different  parts.  There  may  be  marked  Assuring  in 
some  cases  and  a  complete  absence  in  others.  The  size  of  the  placenta  also 
varies  considerably,  the  largest  development  being  found  in  uniovular  twin 
cases. 

There  are  many  variations  as  regards  shape.     Thus,  it  may  be  rounded, 


308  AM ERICA N   TEXT-BOOK    OF    OBSTETRICS. 

oval,  ovoid,  reniform,  crescentic,  regularly  or  irregularly  lobed.  One  or 
more  detached  portions  may  exist — placenta  succenturiata.  The  latter  may  be 
related  to  maternal  blood,  just  like  the  main  part  of  the  placenta.  Rarely 
the  detached  portion  may  be  as  large  as  that  to  which  the  cord  is  attached, 
explaining  what  is  sometimes  described  as  a  double  placenta  with  a  single 
fetus.  In  such  a  condition  the  cord  may  end  in  the  membranes  between  the 
placental  portions,  its  vessels  going  to  each.  Sometimes  the  villi  of  the 
detached  part  are  functionless.     Such  have  been  named  "placenta  spuria." 

Arery  rarely  the  placenta  may  extend  around  the  uterus  in  a  ring-like 
manner,  similar  to  the  condition  found  in  some  mammalia.  Sometimes  it  has 
a  gap  in  its  substance — " placenta  fenestrata"  The  cord  may  have  a  central, 
lateral,  or  marginal  insertion.  In  the  latter  instance  the  appearance  is  often 
compared  to  a  battledore. 

Rarely  it  may  be  inserted  into  the  membranes,  its  vessels  running  in  the 
chorion  to  the  placenta — celamentous  insertion. 

Myxomatous  Degeneration. — This  change  has  been  described  in  connec- 
tion with  hvdatidiform  changes  in  the  chorion.  The  effect  on  the  fetus 
depends  mainly  on  the  amount  of  change  in  the  villi. 

Calcareous  Deposits. — Occasionally  small  portions  of  calcareous  material 
are  found  on  the  maternal  surface  of  the  placenta.  They  may  be  in  the 
decidua,  attached  to  the  ends  of  the  villi,  or  sometimes  in  the  substance  of 
the  latter.     Their  causation  is  unknown. 

Edema. — The  placenta  is  sometimes  swollen  and  edematous.  The  causes 
are  probably  both  maternal  and  fetal,  but  are  not  well  understood.  It  has 
been  noted  with  obstructive  conditions  in  fetal  circulation. 

Fibrous  Degeneration. — This  change  in  the  stroma  of  the  chorionic 
membrane  and  villi  is  a  very  common  one  in  the  advanced  stages  of  normal 
pregnancy,  and  there  is  no  evidence  that  it  is  any  indication  of  a  diseased 
process.  The  delicate  mucoid  stroma  of  the  early  weeks  gradually  changes 
into  a  dense  structure,  in  many  parts  resembling  connective-tissue  sclerosis. 
There  is  a  relatively  large  quantity  of  the  matrix  in  proportion  to  the  nuclei. 
Many  cells  are  shrivelled  and  lie  in  spaces.  In  many  of  the  vessels  great 
thickening  of  the  intima  is  found.  Remains  of  the  early  mucoid  tissue  are 
only  to  be  found  usually  in  some  of  the  small  (latest  formed)  villi. 

In  many  of  the  villi  attached  to  the  decidua  the  disappearance  of  the 
covering  epithelium  may  make  the  connective  tissue  of  the  stroma  appear  to 
be  continuous  with  that  of  the  decidua,  and  it  may  be  difficult  in  some 
instances  to  distinguish  between  them. 

Fatty  Degeneration. — This  has  been  described  as  occurring  when  the 
nutrition  of  the  villi  is  interfered  with,  frequently  in  connection  with 
fibrous  changes  in  the  villi,  and  following  death  of  the  fetus  where  the 
placenta  is  not  immediately  expelled. 

Inflammation. — The  relation  of  the  placenta  to  inflammation  is  not  at  all 
well  understood.     Much  of  the  work  published  dealing  with  diseased  condi- 


PREGNANCY. 


Plate  22. 


Anomalies  of  the  Placenta:  i,  placenta  with  irregular  lobes;  2,  placenta  in  two  unequal 
lobes;  3,  irregular  placenta;  4,  small  accessory  placenta;  5,  placenta  succenturlata ;  6,  "battledore" 
placenta,  oval ;  7,  placenla  with  velamentous  attachment  of  cord  ;  8,  placenta  with  two  equal  lobes. 


THE  PATHOLOGY   OF  PREGNANCY.  309 

tions  is  worthless  because  it  has  been  done  when  the  true  nature  of  the 
placenta  was  not  correctly  known. 

As  regards  the  very  small  portion  of  placental  tissue  of  maternal  origin, 
viz.,  the  decidua  to  which  the  villi  are  attached,  there  is  no  doubt  that  occa- 
sionally it  may  be  affected  along  with  the  rest  of  the  mucosa  in  an  inflamma- 
tory process  often  termed  "  deciduitis."  That  the  change  may  spread  to  the 
attached  villi  is  undoubtedly  possible. 

As  to  inflammation  in  the  main  tissue  of  the  placenta,  which  is  entirely 
of  fetal  origin,  we  know  little.  Fraenkel  has  shown  that  such  a  process  is 
not  infrequent  in  syphilis.  He  has  described  the  infiltration  of  villi  with 
inflammatory  products,  resulting  in  hypertrophies  and  distortions. 

Syphilis. — "While  the  influence  of  syphilis  in  its  various  forms  on  the 
life  of  the  ovum  has  been  well  described  from  the  clinical  point  of  view,  we 
are  as  yet  in  want  of  correspondingly  accurate  data  regarding  the  pathologic 
changes  accompanying  its  different  manifestations. 

This  is  largely  due  to  the  rarity  of  specimens  of  the  pregnant  uteri 
removed  from  syphilitic  women.  The  ovum  alone  is  often  enough  obtained, 
but  no  complete  account  of  the  pathology  can  be  given  until  the  condition  of 
the  uterus  has  been  carefully  studied.  It  is  of  extreme  importance  to  ascer- 
tain whether  the  vessels  and  other  tissues  of  the  maternal  mucosa  are  affected 
in  all  forms  of  the  disease,  or  only  in  certain  cases ;  whether  local  maternal 
changes  are  necessarily  preliminary  to  fetal  changes ;  which  of  the  fetal 
structures  are  most  prone  to  be  affected,  and  what  are  the  variations  related 
to  the  different  kinds  of  syphilitic  infection.  At  present,  it  is  sufficient  to 
state  that  inflammatory  changes  and  gummatous  formations  have  been 
described  in  the  decidual  tissue.  Endarteritis  has  also  been  noted.  In  the 
chorionic  membrane  and  villi  chronic  thickening,  due  to  inflammatory  prod- 
ucts, may  easily  be  demonstrated.  Infarcts  in  the  placenta  are  common. 
When  numerous  and  of  old  standing  they  lead  to  the  destruction  of  many 
portions  of  the  placenta,  which  are  recognized  as  whitish  or  yellowish  firm 
areas.  Thrombosis  in  the  intervillous  space  may  also  occur,  the  thrombi 
when  of  long  standing  becoming  organized,  the  resulting  fibrous  tissue  com- 
pressing and  destroying  many  villi. 

Cysts. — These  are  occasionally  found  especially  near  the  fetal  surface  of 
the  placenta.  Some  are  believed  to  arise  from  a  localized  myomatous  degen- 
eration of  the  chorion,  others  from  the  degeneration  of  infarcts  and  hemor- 
rhages. 

Tumors. — The  myxomatous  and  fibromyxomatous  swellings  have  already 
been  noted.  Occasionally  a  single  large  swelling  occurs  of  combined  fibrous 
and  myxomatous  nature.  Sometimes  the  swelling  may  consist  mainly  of 
angiomatous  structure,  the  tumor  being,  therefore,  a  fibromyxoma  telangi- 
ectodes. These  forms  probably  arise  in  the  chorion.  Albert  has  collected 
a  number  of  these  cases,  and  has  pointed  out  the  frequency  of  abnormal- 
ities in  connection  with  the  pregnancy — e.  g.,  hydramnios,  hemorrhages, 
premature  emptying  of  the  uterus.     Certain  tumors  described  as  fibromata 


310  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

are  probably  merely  organized  blood-clots  or  thromboses.  In  this  connec- 
tion deciduoma  malignum  may  be  mentioned,  as  the  new  growth  usually 
develops  in  connection  with  placental  remains.  In  some  cases  the  disease 
probably  begins  before  the  birth  of  the  ovum. 

Tuberculosis. — The  effects  of  tuberculous  infection  on  the  placenta  are 
not  fully  known.  Local  lesions  have  been  noted  in  the  decidua  and  in  the 
chorion.  In  cases  in  which  the  mother  shows  distinct  tuberculosis  else- 
where tubercle  bacilli  may  be  found  in  the  fetal  tissues,  though  no  changes 
exist  in  the  placenta. 

Placental  Infarcts  and  Apoplexies. — The  frequent  occurrence  in  the 
placenta  of  localized  areas  of  pale  dense  tissue  has  been  noted  by  many  ob- 
servers, and  different  views  have  been  advanced  to  explain  their  formation. 
Perhaps  the  most  widely  held  opinion  is  that  which  regards  them  as  due 
to  hemorrhages  in  the  placenta.  In  the  light  of  recent  work  it  would  appear 
that  this  explanation  is  not  correct. 

Indeed,  true  apoplexies  or  localized  extravasations  of  maternal  blood  are 
very  rare. 

Williams,  one  of  the  most  recent  workers  in  this  subject,  supports  the 
view  originally  advanced  by  Ackermann  that  the  primary  cause  of  infarct 
formation  is  to  be  found  in  the  thickening  of  vessels  in  the  villi,  mainly  in 
the  inner  wall.  As  a  result,  he  states  there  is  a  coagulation-necrosis  of  por- 
tions of  the  villi  just  beneath  the  syncytium,  with  subsequent  formation  of 
canalized  fibrin.  As  the  process  advances  the  syncytium  degenerates  and  is 
changed  into  canalized  fibrin.  This  is  followed  by  the  coagulation  of  the 
blood  in  the  intervillous  space,  which  results  in  the  matting  together  of 
groups  of  villi  by  masses  of  fibrin.  In  the  advanced  stages  the  stroma  of 
the  villi  degenerates,  so  that  it  resembles  the  fibrin  around  it.  Moderate 
degrees  of  infarct  formation' are  not  to  be  regarded  as  pathologic,  being 
frequently  found  in  normal  cases,  but  are  probably  due  to  senile  changes  in 
the  chorion.  There  is  no  doubt  that  diminution  of  caliber  of  the  vessels  of  the 
chorion  is  a  normal  change  toward  the  end  of  pregnancy,  owing  to  thicken- 
ing of  the  intima.  The  endothelium  is  swollen  in  some  parts  and  prolifer- 
ated in  others,  while  often  an  appearance  like  hyaline  degeneration  is  noted. 
These  infarcts  are  for  the  most  part  white  or  yellow  in  color ;  they  vary  in 
size  from  small  dots  to  large  portions  of  the  placenta.  They  may  be  found 
next  the  amniotic  surface  in  the  substance  of  the  placenta,  or  at  the  maternal 
surface  ;  frequently  they  are  situated  at  the  edge.  Sometimes  they  are  found 
as  a  thick  band  running  around  the  fetal  surface  at  some  distance  from  the, 
edge.  In  the  latter  condition  the  placenta  is  often  termed  placenta  mar- 
ginata.  In  some  cases  this  ring-like  band  is  found  half  an  inch  or  more 
internal  to  the  edge.  Rarely  pinkish  infarcts  are  noted,  and  still  more  rarely 
bright-red  or  dark  plum-colored  masses  are  found.  Occasionally  white 
infarcts  are  found,  termed  by  Eden  "  non-fibrinous."  These  are  an  agglom- 
eration of  villi  not  bound  together  with  fibrin.  Marked  infarct-forma- 
tion  may  be  noted  in  various  diseased  conditions  of  the  mother,  particularly 


1HE   PATHOLOGY    OF  PREGNANCY.  311 

where  there  is  albuminuria.     They  may  be  found  in  syphilitic  cases,  though 
they  are  not  particularly  characteristic  of  this  condition. 

D.  Umbilical  Coed. 

Anomalies. — -The  cord  presents  many  peculiarities  of  development.  It 
may  be  abnormally  long — sometimes  measuring  five  or  six  feet.  It  may  be 
very  short — being  four  or  five  inches  in  length.  The  latter  condition  is  to  be 
distinguished  from  relative  shortness,  an  artificial  production  due  to  excess 
of  convolutions  around  the  fetus,  or  to  adhesions  to  the  amnion  or  amniotic 
bands.  The  cord  may  sometimes  not  enter  the  placenta,  but  may  end  in  the 
membranes  at  various  distances  from  its  edge,  the  vessels  separating  and  run- 
ning in  the  chorion  to  the  villi. 

The  Whartonian  jelly  of  the  cord  may  be  very  irregularly  distributed  ;  in 
some  parts  it  may  be  almost  entirely  absent,  so  that  the  diameter  of  the  cord 
is  much  diminished. 

Sometimes  the  cord  may  contain  two  veins  and  one  artery,  or  one  vein 
and  one  artery ;  sometimes  two  cords  pass  to  one  placenta. 

Torsion. — The  vessels  in  the  cord  are  variously  related  to  one  another  ; 
usually  the  arteries  are  coiled  around  the  vein,  running  from  right  to  left, 
causing  a  twisted  appearance  ;  sometimes  they  run  from  left  to  right ;  some- 
times they  run  parallel  almost  the  whole  length  of  the  cord,  very  few  turns 
existing. 

Some  variations  are  probably  natural,  but  many  cases  occur  in  which 
marked  torsion  of  the  whole  cord  on  its  longitudinal  axis  is  due  to  move- 
ments of  the  fetus.     In  most  cases  the  torsion  is  most  evident  near  the  fetus. 

Occasionally  the  turns  are  so  numerous  as  to  make  the  cord  resemble  a 
coil  of  wire  spring.  In  one  case  noted  by  Schauta,  three  hundred  and  eighty 
twists  were  counted.  Edema  and  cystic  changes  have  been  found  with 
marked  torsion.  Great  narrowing  of  the  cord  and  partial  or  complete  oblit- 
eration of  its  vessels  may  also  be  brought  about. 

Convolution. — The  cord  may  be  arranged  in  various  ways  in  relation, 
to  the  fetus.  Frequently  it  passes  from  the  umbilicus  up  over  the  chest, 
around  the  neck,  and  down  in  front  of  the  other  shoulder.  Occasionally  it  is 
coiled  once  or  several  times  around  the  neck,  body,  or  limbs.  The  largest 
number  of  turns  around  the  body  yet  described  is  nine. 

Extra  convolutions  are  almost  always  associated  with  abnormal  length  of 
cord.  Division  of  the  soft  tissues  of  the  neck  has  been  rarely  noted  as  the 
result  of  coiling ;  amputation  of  a  limb  has  been  more  frequently  described. 
Direct  strangulation  of  the  child  is  very  rare.  As  regards  labor,  Bruttau,  of 
Dorpat,  where  convolution  of  the  cord  is  frequently  observed,  points  out  that 
stillborn  children  are  not  more  frequent  than  in  cases  where  convolutions 
are  absent.  Though  a  larger  percentage  are  born  more  or  less  asphyxiated, 
there  is  more  risk  of  pressure  on  the  cord  in  primiparse.  The  greatest  risk 
exists  where  there  is  dystocia  of  some  form.     Excessive  convolution   may 


312  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

cause  delay  in  labor  when  the  free  portion  of  the  cord  is  thereby  made 
very  short. 

Knots  of  the  Cord. — Occasionally  the  cord  may  be  knotted  as  a  result 
of  the  movements  of  the  fetus  in  utero  during  pregnancy ;  sometimes  it  may 
occur  during  labor.  Generally,  only  one  knot  is  formed,  but  there  may  be 
more.  In  the  case  of  twins  in  a  single  amniotic  sac  there  may  be  marked 
twisting  or  knotting  of  the  cords. 

In  the  great  majority  of  instances  no  damage  results  to  the  fetus  from  the 
presence  of  these  knots,  since  they  are  usually  loose.  Very  rarely  is  the 
circulation  interfered  with.  The  Whartonian  jelly  may  be  displaced  where 
the  folds  of  the  knots  cross,  in  cases  where  they  are  of  some  duration. 

Sometimes  a  condition  of  the  cord  exists  to  which  the  term  "  false  knot"  has 
been  given,  to  distinguish  it  from  the  above-described  "  true  knot."  It  con- 
sists of  a  projection  along  the  course  of  the  cord,  due  to  a  localized  accumu- 
lation of  Whartonian  jelly,  or  to  a  sharp  bend  or  curve  in  one  of  the  vessels. 

Changes  in  the  Vessels. — The  alterations  associated  with  maternal  and 
fetal  diseases  have  not  been  well  established.  Winckel  and  Swieciki  have 
pointed  out  the  frequency  of  narrowing  of  the  vessels  from  changes  in  the 
intima  and  outer  wall  in  syphilis,  heart  and  kidney  diseases  of  the  mother, 
and  in  other  affections.     The  vein  or  the  arteries,  or  both,  may  be  affected. 

Torsion  may  lead  to  a  partial  or  complete  stenosis  of  the  vessels.  Vari- 
cose enlargements  occasionally  occur ;  rupture  has  been  described. 

Hernia. — Sometimes,  at  birth,  the  fetal  abdominal  viscera  lie  in  a  hernial 
extension  into  the  cord.  Otherwise  the  fetus  may  be  healthy,  but  frequently 
some  other  abnormality  exists — e.g.,  imperforate  anus,  malformations  of  outer 
genitals,  etc.  The  hernia  varies  in  size.  It  may  contain  only  small  intestine, 
but,  in  some  cases,  large  intestine,  stomach,  liver,  and  other  viscera. 

Swellings  of  the  Cord. — These  are  rare.  Cysts  are  sometimes  found ; 
blood  effusions  ;  myxomata  ;  telangiectatic  myxofibromata. 

6.  Premature  Expulsion  of  the  Uterine  Contents. 
Abortion  ;  Miscarriage. 

Definition. — By  many  the  term  abortion  is  applied  to  expulsion  of  the 
ovum  during  the  first  three  months  ;  miscarriage,  to  expulsion  during  the 
second  three  months ;  premature  labor,  to  expulsion  during  the  last  three 
months.  Others  use  the  first  two  terms  synonymously,  referring  to  expulsion 
of  the  ovum  before  viability  of  the  fetus  ;  in  the  great  majority  of  cases  this  - 
takes  place  in  the  twenty-eighth  week.  In  this  section  the  latter  definition 
is  employed. 

Frequency. — No  accurate  statement  can  be  made  regarding  the  frequency 
of  premature  emptying  of  the  uterus.  Statistics  given  by  different  authori- 
ties vary  considerably.  Thirty-seven  per  cent,  of  all  child-bearing  women 
are  said  to  abort  at  least  once  before  the  age  of  thirty-one,  and  after  this  the 
percentage   is   higher.      Probably   many  very  early  pregnancies   terminate 


THE   PATHOLOGY   OF  PREGNANCY.  313 

without  being  recognized  as  an  abortion,  the  attendant  hemorrhage  being 
regarded  as  a  menstrual  disturbance.  Abortion  is  much  less  frequent  during 
the  first  than  during  succeeding  pregnancies.  The  third  and  fourth  months 
are  those  in  which  it  is  most  apt  to  take  place.  Very  often  the  date  of  its 
occurrence  is  that  corresponding  to  a  menstrual  period. 

Etiology. — The  causes  of  abortion  are  very  numerous,  being  all  condi- 
tions which  set  up  uterine  action.  They  are  often  classified  as  maternal, 
fetal,  and  paternal ;  but  it  is  impossible  to  arrange  them  into  distinct  divi- 
sions, assigning  to  each  a  definite  form  of  action.  In  many  cases  more  than 
one  factor  is  in  operation,  and  it  is  often  impossible  to  state  which  is  the 
most  important  determining  cause.  Thus,  there  are  many  maternal  condi- 
tions in  which  abortion  occurs,  in  which  the  causal  factors  may  be  a  high 
febrile  state,  poisons  circulating  in  the  blood  which  may  cause  death  of  the 
fetus,  intra-uterine  hemorrhages  causing  fetal  death  or  stimulating  the  uterus 
to  contraction. 

Speaking  generally  as  regards  the  mother,  conditions  which  are  associated 
with  high  temperature,  extreme  exhaustion,  nervous  shock,  accumulation  of 
poisons  in  the  blood,  hemorrhages  in  the  decidua  or  in  the  attached  fetal 
structures,  or  which  lead  to  mechanical  interference  with  the  normal  devel- 
opment of  the  pregnant  uterus,  are  among  the  most  important  causes  leading 
to  abortion.  Among  such  conditions  are:  (1)  The  acute  infectious  diseases, 
syphilis,  tuberculosis ;  (2)  various  diseases  of  the  nervous,  urinary,  circula- 
tory, respiratory,  and  alimentary  systems ;  (3)  various  inflammations,  dis- 
placements, and  neoplasms  of  the  uterus  and  other  pelvic  structures ;  (4)  all 
forms  of  mental  shock  and  emotional  excitement ;  (5)  traumatism,  e.  g., 
dancing,  riding,  falls,  passage  of  foreign  bodies  into  the  uterus,  etc. 

As  regards  the  ovum,  there  are  many  factors  which  lead  to  abortion, 
either  by  causing  death  of  the  fetus  or  by  stimulating  the  uterine  muscle 
directly.  Such  are  diseases  and  abnormalities  of  the  chorion,  amnion,  or 
cord — hydramnios ;  sudden  escape  of  liquor  amnii ;  diseases  or  malforma- 
tions of  the  fetus  causing  its  death. 

The  paternal  influences  causing  abortion  are  not  well  understood.  Syph- 
ilis is  the  best  known.  Tuberculosis  and  some  other  conditions  markedly 
affecting  health  are  believed  in  some  cases  to  induce  premature  emptying  of  the 
uterus.     Advanced  age  or  extreme  youth  is  thought  to  act  in  the  same  way. 

Symptoms. — Signs  of  Abortion.— -These  vary  greatly.  The  chief  clinical 
phenomena  are:  (1)  Pains  in  the  pelvis;  (2)  hemorrhage;  (3)  expulsion  of 
part  or  the  whole  of  the  ovum  and  decidual  tissue. 

In  some  cases  the  uterine  contents  may  be  expelled  suddenly  without  the 
previous  occurrence  of  any  of  the  above  symptoms.  As  an  illustration  may 
be  mentioned  the  case  of  a  woman  who  passed  a  three  months'  ovum  while  in 
the  middle  of  a  dance,  without  any  warning  whatever.  In  some  cases  pain 
is  entirely  absent ;  in  others  there  may  be  little  or  no  bleeding  before  the 
ovum  is  expelled.  Sometimes  only  blood-serum  escapes ;  sometimes  the 
liquor  amnii  first  gushes  out. 


314 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


Very  frequently  paiu  is  early  felt  in  the  sacral  region  as  a  continuous 
aching.  Often,  intermittent  labor-like  pains  are  present.  Fulness  and 
weight  in  the  pelvis  and  frequency  of  micturition  may  be  noted.  Bleeding 
may  precede  pains,  may  be  noticed  synchronously,  or  may  follow  them.  The 
blood  may  pass  in  driblets  or  as  a  profuse  flow.  It  may  collect  in  the  vagina 
and  form  large  clots ;  or  it  may  be  retained  in  the  uterus,  distending  it  and 
increasing  the  pain.  Clotting  may  occur  in  the  cervix,  only  blood-serum 
escaping.  Sometimes  bleeding  takes  place  only  at  night  when  the  patient 
lies  down,  ceasing  when  she  walks  about.  This  is  probably  due  to  the  sink- 
ing down  of  the  reflexa  and  ovum,  acting  as  a  plug  to  the  internal  os  while 
the  woman  is  in  the  erect  posture. 

The  duration  of  an  abortion  varies  greatly.  As  just  stated,  it  may  take 
place  in  a  very  few  seconds,  so  far  as  the  woman's  subjective  knowledge  is 
concerned.      Ordinarily  it  lasts  over  a  period  of  several  hours.      In  some 


Fig.  151.— Ovum  imbedded  in  blood-clot  (Ahlfeld). 

cases  the  phenomena  may  extend  over  several  days,  being  more  or  less 
constant  or  intermittent  in  character.  When  the  abortion  is  not  complete, 
certain  effects  may  be  produced  which  may  be  evident  months  or  years 
afterward. 

On  physical  examination,  in  the  early  stages  of  abortion,  the  enlarged 
uterus  may  be  palpated.  When  pregnancy  is  advanced  only  two  or  three 
weeks,  it  is  impossible  to  be  certain  as  to  the  degree  of  enlargement.  Usu- 
ally variations  in  its  consistence — alternate  hardening  and  softening — may 
be  distinguished. 

Very  early  no  dilatation  of  the  cervix  may  be  felt,  even  though  blood 
be  escaping  from  it.  Later  it  is  more  or  less  patulous,  so  that  a  finger 
may  readily  be  introduced,  and  presenting  portions  of  decidua,  ovum,  or 
blood-clot  may  be  felt  (see  Figs.  152,  153). 

Mechanism  of  Abortion. — Berry  Hart  has  pointed  out  that  in  many 
cases  in  which  a  complete  abortion  is  expelled  there  may  be  a  definite  mech- 


THE   PATHOLOGY   OF  PREGNANCY.  315 

anism,  which  he  terras  "  normal."  Of  this  there  are  two  varieties  :  First, 
that  in  which  expansion  of  the  lower  uterine  segment  is  accompanied  by  a 
separation  of  the  decidua  vera  from  below  upward,  the  whole  mass  expelled 
consisting  of  the  outer  portion  of  the  vera  and  serotina,  reflexa,  and  contained 
ovum  ;  second,   that  in   which,  as  the  vera  gets  separated,  the  reflexa  and 


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it.' 


v  \ 


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,r   ? 


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s 


."-: 


Pig.  152.— Frozen  section  of  the  uterus,  showing  placenta  and  partially  detached  membranes  (Freund). 

superficial  part  of  the  serotina,  with  the  contained   ovum,  are  driven   down 
into  the  cervix,  the  vera  following  afterward  as  the  abortion  proceeds. 

As  regards  the  separation-plane  in  the  case  of  a  complete  abortion,  my 
researches  show  that  it  passes  mainly  through  the  compact  layer  of  the  sero- 
tina and  vera  in  the  middle  or  outer  part ;  in  certain  areas  the  whole 
compact  layer  and  bits  of  the  spongy  layer  may  be  shed.  It  is  exceptional  to 
find  any  considerable  quantity  of  the  latter  removed. 


316 


AMERICAN   TEXT-]  10 OK    OF    OBSTETRICS. 


Probably  the  majority  of  abortions  do  not  occur  in  this  normal  manner; 
very  often  the  uterine  contents  come  away  in  successive  portions,  the  expul- 
sion often  being  only  partial.  In  these  abnormal  cases  sometimes  every- 
thing may  escape  except  the  vera.     The  reflexa  along  with  the  superficial 


f,  V 


Fig.  153.— Frozen  section  of  the  uterus,  showing  retained  membranes  iFreund). 

part  of  the  serotina  and  the  contained  ovum  may  easily  be  mistaken  for  a 
complete  abortion  on  superficial  examination.  In  some  cases  parts  only  of 
the  vera  may  be  left ;  in  other  cases  parts  or  the  whole  of  the  serotina  may 
be  left  along  with  attached  villi  and  more  or  less  of  the  reflexa. 

Sometimes  the  reflexa  may  be  broken  off  at  its  junction  with  the  serotina 


THE   PATHOLOGY    OF  PREGNANCY.  317 

and  expelled  with  or  without  the  amniotic  sac  and  its  contents.  Sometimes 
the  fetus  alone  or  the  entire  ovum  may  be  expelled  through  the  reflexa,  the 
decidual  structures  being  expelled  partly  or  entirely  at  a  later  date.  Occa- 
sionally the  entire  amnion  and  its  contents  may  alone  be  expelled. 

Varieties. — Different  terms  are  employed  to  describe  the  various  stages 
in  which  abortions  are  met  with  clinically. 

Threatened  Abortion. — This  condition  is  one  in  which  there  are  symptoms 
pointing  to  the  commencement  of  expulsion  of  the  uterine  contents.  As 
already  indicated,  these  vary  in  different  cases.  Ordinarily  there  are  pelvic 
pains,  with  or  without  hemorrhage,  and  with  little  or  no  dilatation  of  cervix. 

In  many  cases  of  early  pregnancy  the  threatening  occurs  at  the  time  cor- 
responding to  a  menstrual  period. 

Inevitable  Abortion. — This  is  the  condition  in  which  the  threatening  symp- 
toms have  become  more  marked  and  persistent,  so  that  all  hope  of  preventing 
the  abortion  must  be  given  up.  In  this  stage  usually  the  cervix  is  dilated,  so 
that  a  finger  may  be  introduced.  Often,  however,  it  cannot  be  passed  through 
the  internal  os.  Expulsion  of  portions  of  the  decidua  vera  is  generally 
2'egarded  as  a  sign  of  inevitable  abortion  ;  but  this  is  not  always  the  case, 
for  occasionally  this  may  take  place  in  a  threatening  abortion,  pregnancy 
continuing  afterward. 

Complete  Abortion. — This  is  the  condition  in  which  everything  which 
should  be  expelled  escapes  from  the  uterus.  The  constituents  of  the  com- 
plete abortion  have  already  been  described. 

Incomplete  Abortion. — In  this  condition  there  are  left  in  the  uterus  de- 
cidual tissue,  fetal  structures,  or  parts  of  both.  The  variations  which  occur 
have  previously  been  noted. 

Habitual  abortion  is  the  term  applied  to  the  repeated  occurrence  of  abor- 
tion in  the  same  woman.  In  some  instances  pregnancy  may  be  interrupted 
successively  at  the  same  period  ;  in  other  cases,  however,  the  time  is  variable. 

Hissed  Abortion. — Occasionally  a  fetus  may  die  in  uiero  and  no  abortion 
occur  ;  in  some  cases  no  threatening  even  taking  place  at  the  time  of  fetal 
death.  The  uterus  may  retain  its  contents  for  weeks  or  months.  This  may 
happen  to  twin  pregnancies  as  well  as  to  single  ones.  Sometimes  both  ova 
may  perish,  sometimes  only  one.  The  latter  may  be  the  case  even  when 
both  fetuses  lie  in  one  amniotic  cavity.  When  exjndsion  finally  does  occur, 
the  uterine  contents  present  various  appearances  in  different  cases.  Some- 
times the  fetus  is  preserved  in  a  shriveled  condition,  wrapped  up  in  the 
membranes  and  placenta,  the  liquor  amnii  having  been  absorbed  or  pre- 
viously expelled.  The  term  "blighted  ovum"  is  applied  to  this  condition. 
In  other  instances  the  ovum  and  decidual  tissues  are  largely  altered  by 
hemorrhagic  effusions,  forming  a  mass  termed  the  carneous,  fleshy,  or  sarcous 
mole,  or  molar  abortion.  The  fetus  may  be  entirely  or  partially  absorbed ; 
sometimes  only  a  small  part  of  the  umbilical  cord  may  be  recognized.  The 
villi  in  these  masses  are  found  in  various  stages  of  degeneration,  similar  to 
those  already  described  in  placental  infarcts.     The  blood  may  be  found  in  all 


318 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


stages  from  the  recently  effused  red  clot  to  the  well-advanced,  organized, 
pale  fibrin  mass. 

In  some  early  abortions  may  be  noticed  hemorrhagic  effusions  in  the 
decidua  and  chorion,  forming  bulgings  into  the  amniotic  cavity.  To  this 
appearance  Breus  has  given  the  name  of  "  tuberose  subchorionic  hematoma 
of  the  decidua."  When  an  immediate  abortion  does  not  occur  as  the  result 
of  this  condition,  a  carneous  mole  usually  develops. 

The  clinical  history  in  cases  of  missed  abortion  varies.  Usually  after  a 
period  of  amenorrhea,  during  which  various  signs  and  symptoms  of  preg- 
nancy are  present,  there  is  hemorrhage  from  the  uterus  and  perhaps  some  of 
the  other  signs  of  abortion  (often  believed  to  be,  by  the  patient,  an  actual 


Fig.  154. — Tuberose  subchorionic  hematoma  of  the  decidua  (Webster),  a,  Amniotic  surface  of  early 
abortion-sac ;  6,  embryo ;  c,  large  blood-clot  in  decidua  forming  a  bulging  in  amniotic  cavity ;  d,  small 
blood-clots. 


abortion),  and  afterward  another  period  of  amenorrhea,  lasting  for  weeks 
or  months  until  the  mass  is  expelled  from  the  uterus. 

Instead  of  a  second  period  of  amenorrhea,  there  may  be  irregular  dis- 
charges of  blood.  Occasionally,  putrefactive  changes  may  occur  and  a  fetid 
discharge  result.  Sometimes  septic  infection  may  occur.  During  this  latter 
period  the  uterus  may  diminish  somewhat  in  size,  thereafter  remaining  in  a 
stationary  degree  of  enlargement,  or  it  may  become  slowly  and  progressively 
larger  owing  to  a  succession  of  fresh  hemorrhages  in  the  ovum. 

The  length  of  time  that  a  missed  abortion  may  remain  in  the  uterus  is 
not  definitely  known,  and  accurate  observations  are  wanting.  The  subject,  is 
of  considerable  importance  from  the  medicolegal  point  of  view,  as  was 
recently  shown  in  the  well-known  trial  in  London,  "  Ivitsou  vs.  Playfair." 
Dr.  Playfair  removed  from  a  woman  on  February  23,  1894,  a  piece  of  tissue 
left  after  an  abortion  which  was  regarded  by  him  as  of  recent  origin.     The 


THE   PATHOLOGY   OF  PREGNANCY.  319 

woman  maintained  that  it  was  a  portion  of  the  product  of  a  conception  which 
had  occurred  at  least  eighteen  months  previously,  being  part  of  a  blighted 
ovum  retained  in  the  uterus  from  October,  1892,  when  the  threatening  of  an 
abortion  had  occurred  resulting  in  the  death  of  the  fetus. 

No  difficulty  should  exist  in  the  determination  of  the  probable  age  of  an 
abortion.  If  the  chorionic  tissue  be  of  recent  origin,  well-formed  villi  with 
preserved  epithelium  can  be  made  out,  whereas  in  missed  abortion  of  some 
duration  characteristic  alterations  can  be  made  out.  These  are  :  gradual  dis- 
appearance of  the  fetal  epithelium,  amniotic  and  chorionic,  fibrin  formation 
in  the  blood  of  the  intervillous  spaces,  gradual  invasion  of  the  fibrin  by  con- 
nective tissue  of  decidual  type.  Fothergill  believes  that  these  decidual  cells 
gradually  absorb  the  fibrin  and  the  remains  of  epithelial  cells.  Thus,  the 
connective-tissue  cores  of  the  villi  tend  to  be  surrounded  by  decidual  tissue, 
the  whole  forming  a  firm  mass.  To  it  Hartman  and  Toupet  have  applied 
the  name  "  deciduoma  benignum." 

Prognosis. — Loss  of  the  mother's  life  rarely  accompanies  spontaneous 
abortion.  Yet  a  fatal  result  may  sometimes  take  place  from  hemorrhage  or 
rupture  of  the  uterus  ;  sometimes  it  may  be  due  to  an  acute  or  chronic  infec- 
tive process.  Deciduoma  malign  urn  may  develop  in  connection  with  abor- 
tion, causing  death. 

In  many  cases  results  follow  which  do  not  prove  fatal,  but  lead  to  much 
ill  health.  These  are  mainly  associated  with  incomplete  abortions,  which 
may  lead  to  protracted  loss  of  blood,  to  the  development  of  a  fibrin  polypus, 
to  subinvolution  of  the  uterus  with  hypertrophied  and  congested  mucosa,  and, 
in  cases  of  infection,  to  various  forms  of  pelvic  and  systemic  disturbances. 

Complete  abortion  may  be  followed  by  ill  health,  due  to  great  loss  of 
blood  or  to  the  results  of  septic  infection.  A  rapid  succession  of  abortions 
usually  leads  to  deterioration  of  the  system  from  one  or  more  of  the  above 
causes. 

Many  women  injure  themselves  by  regarding  an  abortion  as  a  matter  of 
no  importance.  They  either  refuse  to  cease  from  the  ordinary  routine  of 
their  life,  or,  if  they  go  to  bed,  rise  too  soon  and  work  too  early.  As  a  con- 
sequence, protracted  weakness,  subinvolution,  displacements,  etc.,  are  apt  to 
result. 

In  criminal  abortion  the  risks  to  the  mother  are  enormously  increased, 
owing  to  the  unskilful  use  of  instruments,  to  the  lack  of  aseptic  measures, 
or,  when  drugs  are  employed,  to  their  destructive  effects  on  the  system. 

Differential  Diagnosis. — There  are  difficulties  of  diagnosis  in  connection 
with  the  different  varieties  of  abortion.  A  threatened  abortion  may  simulate 
a  number  of  conditions,  and  vice  versa.  The  most  important  point  in  mak- 
ing a  diagnosis  is  to  determine  whether  or  not  pregnancy  exists.  To  do  this 
is  often  impossible,  especially  in  the  early  weeks.  Consequently  there  is 
often  much  uncertainty  in  diagnosing  abortion. 

In  women  who  have  irregular  menstruation,  a  flow  of  blood  coming  on 
after  several   weeks   of  amenorrhea,   mav  be  mistaken  for  abortion.     The 


320  AMERICAN    TEXT- BO  OK    OF    OBSTETRICS. 

error  is  more  easily  made  when  the  flow  is  accompanied  with  uterine  pains 
of  a  labor-like  character.  The  case  may  be  more  complicated  when  there  is 
some  uterine  enlargement,  such  as  may  be  due  to  inflammation  or  new 
growth  of  the  uterus,  and  when  some  of  the  reflex  signs  and  symptoms  of 
pregnancy  are  present. 

Sometimes  there  may  be  pelvic  pain  and  loss  of  blood  due  to  some  con- 
dition outside  of  the  uterus  altogether — e.  g.,  vaginal  new  growths,  hemor- 
rhoids, etc.  Haultain  has  described  an  interesting  case  in  which  a  clot  in 
the  bladder  caused  dilatation  of  the  sjfliincter  urethra?,  thus  allowing  blood 
to  escape,  a  threatened  abortion  being  closely  simulated. 

A  uterine  hemorrhage  occurring  in  the  course  of  an  ectopic  pregnancy  is 
often  mistaken  for  an  abortion  ;  sometimes  with  serious  results.  In  some 
cases  of  pregnancy  there  is,  in  the  early  months,  an  escape  of  blood  from 
the  uterus  before  the  space  between  vera  and  reflexa  is  obliterated.  It  may 
occur  in  successive  gestations  in  the  same  woman.  Usually  such  a  case  is 
regarded   as  a  threatened  abortion. 

The  fact  of  threatened  abortion  being  established,  it  is  often  difficult  to 
decide  whether  or  not  it  is  inevitable.  If  the  bleeding  be  profuse,  or  if, 
under  treatment,  it  ceases  and  begins  again  ;  if  uterine  contractions  are  fre- 
quent and  strong,  and  continue  in  spite  of  treatment ;  if  the  cervix  be  dilated 
so  that  a  finger  may  feel  parts  of  the  ovum  or  decidua  bulging  into  the  cer- 
vical canal  ;  if  the  amniotic  cavity  be  ruptured,  or  the  fetus  be  dead,  the 
abortion  must  be  regarded  as  inevitable  in  the  great  majority  of  cases. 

Occasionally,  however,  the  physician  makes  a  mistake  and  is  surprised  to 
find  that  abortion  does  not  occur,  even  though  the  symptoms  have  been  so 
marked  as  to  lead  him  to  believe  it  inevitable.  Cases  have  been  recorded  in 
which  even  the  amniotic  cavity  has  been  ruptured  and  yet  pregnancy  has 
continued  to  full  time.  W^itji  regard  to  the  condition  of  the  fetus,  it  is  to 
be  noted  that  in  the  first  three  or  four  months  it  is  impossible  to  know  when 
it  has  died.  Usually  this  occurrence  is  soon  followed  by  emptying  of  the 
uterus,  but  in  a  few  cases  this  does  not  follow,  and  it  is  then  found  that 
there  is  gradual  disappearance  of  the  various  reflex  sympathetic  symptoms 
and  signs  of  pregnancy. 

In  the  early  months  the  latter  may  be  very  slight  in  certain  cases,  and 
their  disappearance  may  therefore  be  unrecognizable.  When  au  abortion 
has  occurred,  it  is  very  important  to  decide  whether  it  has  been  complete 
or  incomplete.  It  is  possible  to  give  a  positive  diagnosis  only  when  the 
physician  is  able  to  examine  what  has  been  passed  from  the  uterus ;  in 
the  great  majority  of  cases  he  is  unable  to  do  this.  If  he  cannot  decide  in 
this  way,  he  may  gain  information  either  by  examining  the  interior  of  the 
organ  under  anesthesia  or  by  watching  the  clinical  phenomena  for  some  time 
after  the  abortion.  The  first  method  is  satisfactory  in  a  certain  measure; 
but  it  is  impossible  to  be  accurate,  especially  with  regard  to  determining 
whether  the  vera  has  separated  or  not.  Whenever  doubt  exists,  the  uterus 
should  be  curetted. 


THE   PATHOLOGY   OF  PREGNANCY.  321 

The  second  method  is  fairly  satisfactory,  though  it  subjects  the  patients 
to  risks.  If  an  abortion  be  incomplete,  the  uterus  does  not  remain  so  firm 
and  small  as  after  complete  expulsion  ;  the  lochial  discharge  is  usually  more 
profuse,  the  loss  of  blood  more  marked  and  remaining  continuous  or  inter- 
mittent for  days  and  weeks,  the  patient  being  in  a  depressed  state  of  health. 

A  complete  abortion  may  itself  be  easily  mistaken  for  other  conditions, 
and  vice  versa.  Thus,  a  period  of  amenorrhea  followed  by  a  loss  of  blood, 
which  may  continue  intermittently  afterward,  with  excessive  leukorrhea  and 
generally  weakness,  may  be  due  to  inflammatory  conditions  of  the  uterus, 
retroversion,  mucous  or  fibroid  polypi,  or  other  conditions.  Sometimes  these 
diseased  states  may  reflexly  set  up  some  of  the  well-known  signs  and 
symptoms  of  pregnancy.  When  a  fibrinous  polypus  has  formed  after  an 
incomplete  abortion,  it  may  easily  be  mistaken  for  a  true  neoplasm,  simple 
or  malignant.  When  putrefactive  changes  take  place  in  the  remains  of  an 
incomplete  abortion,  the  signs  and  symptoms  may  closely  simulate  those  of 
malignant  disease  or  of  a  sloughing  fibroid. 

Missed  abortion  may  often  be  very  difficult  to  diagnose.  Sometimes  it  is 
regarded  as  a  second  pregnancy,  an  abortion  having  been  thought  to  occur 
when  only  a  threatening  has  taken  place.  Generally,  the  pregnancy  is 
regarded  as  continuing  satisfactorily,  following  upon  a  threatened  interrup- 
tion. The  observation  of  a  few  weeks,  however,  shows  that  the  uterus  is 
not  developing  in  a  normal  manner. 

In  some  cases  the  diagnosis  of  new  growth  of  the  uterus  is  made.  This 
is  particularly  apt  to  be  made  if  hemorrhages  occur,  if  the  finger  introduced 
into  the  cervix  feels  a  mass  in  the  cavity,  or  if  putrefaction  has  begun  in 
utero  leading  to  a  foul-smelling  discharge. 

Treatment. — Prophylactic. — When  a  woman  has  aborted  once  or  several 
times,  the  most  careful  examination  should  be  made,  and  treatmeut  carried 
out  before  she  becomes  j^regnant  again.  If  her  health  be  much  run  down, 
an  effort  should  be  made  to  restore  it.  If  there  be  a  syphilitic  taint,  the 
parents  should  be  subjected  to  a  long  course  of  antisvpbilitic  remedies  before 
pregnancy  is  allowed  to  occur  again.  Diseased  conditions  in  the  pelvis 
should  be  treated.  Thus,  a  retroverted  uterus  may  require  to  be  replaced  and 
supported  by  a  pessary.  Sometimes  the  removal  of  adhesions  by  operation 
may  be  necessary.  A  tumor  may  require  to  be  taken  away.  If  there  be 
chronic  inflammation  in  the  uterus,  it  should  be  reduced.  After  an  abor- 
tion has  occurred  at  least  a  year  (in  syphilitic  cases  longer)  should  elapse 
before  pregnancy  is  allowed  to  take  place  again. 

AVhen  the  woman  falls  pregnant,  she  must  take  particular  care  of  herself, 
avoiding  excitement  and  fatigue,  and  paying  attention  to  the  digestive  tract. 
She  should  rest  in  bed  during  the  times  corresponding  to  menstrual  periods, 
not  rising  even  to  urinate  or  defecate. 

Coitus  during  pregnancy  should  be  prohibited,  especially  in  the  first  half. 
Purgatives  must  be  avoided.  Iron  and  other  tonics  need  be  given  only  when 
the  system   requires  them.     The   administration  of  potassium   chlorate,   as 

21 


322  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

recommended  by  Simpson,  is  thought  by  many  to  exercise  a  beneficial  influ- 
ence.    The  correction  of  pelvic  disorders  may  be  necessary. 

Threatened  Abortion. — The  patient  must  be  kept  absolutely  at  rest  in  bed. 
For  defecation  and  urination  a  bedpan  should  be  used.  If  the  bowels  do 
not  move  naturally,  laxatives  should  not  be  given  ;  it  is  best  that  the  bowels 
should  remain  quiet  for  a  few  days.  The  diet  should  be  simple,  light,  and 
non-stimulating.  Opium  or  morphin  should  be  administered.  At  first 
if  uterine  contractions  are  marked,  a  hypodermic  injection  (J  gr.)  of  the 
latter  may  be  given,  followed  in  four  hours  by  a  rectal  suppository  (J  gr.). 
This  may  be  repeated  every  four  or  five  hours  until  uterine  contractions  are 
quieted.  Then  the  quantity  may  be  continuously  diminished.  In  some 
cases  the  drug  may  be  continued  several  days.  To  obtain  a  movement  of 
the  bowels  a  glycerin  and  olive  oil  enema  should  be  used.  Viburnum  pru- 
nifolium  (fluid  extract)  given  by  the  month  in  half  drachm  or  drachm  doses 
every  six  or  eight  hours  is  used  by  many  physicians  as  an  accessory  to  the 
morphin.     Chloral  and  bromid  are  also  used. 

When  the  treatment  is  satisfactory,  the  pains  and  hemorrhage  gradually 
disappear.  The  woman  should  then  not  be  allowed  to  rise,  hut  should  be 
kept  at  rest  a  week  or  more.  When  she  gets  up  she  should  be  very  careful 
to  avoid  all  strain,  fatigue,  excitement,  and  worry,  and  should  lie  down  in 
the  middle  of  the  day  for  an  hour  or  two  during  the  succeeding  few  weeks. 
At  the  succeeding  periods  corresponding  to  her  menstruation  she  should 
spend  a  few  days  in  bed. 

Inevitable  Abortion. — There  is  some  difference  of  opinion  as  to  the  best 
method  of  conducting  an  abortion  case.  Should  nature  be  allowed  to  act,  or 
should  artificial  means  be  always  adopted  ?  There  is  no  doubt  that  artificial 
cleaning  out  of  the  uterus,  under  proper  aseptic  precautions,  is  a  most  satis- 
factory procedure,  but  it  is  best  not  to  employ  this  method  unless  conditions 
are  suitable  to  a  perfect  technic.  Very  often  the  patient  will  not  allow  it 
to  be  employed.  The  carelessness  of  women  in  regard  to  the  conduct  of 
abortion  is  much  to  be  deprecated ;  on  the  part  of  the  physician  it  is  unpar- 
donable. The  recklessness  with  which  many  practitioners  carry  out  surgical 
interference  without  any  regard  to  asepsis  is  the  cause  of  much  calamity. 

In  a  number  of  cases  the  uterus  may  be  entirely  emptied  if  the  patient  be 
left  at  rest  in  bed,  and  no  interference  may  be  necessary.  If,  however,  it  be 
feared  that  the  vagina  is  not  aseptic  by  reason  of  digital  examination,  recent 
coitus,  or  some  diseased  condition,  it  is  best  to  make  use  of  antiseptic  agen- 
cies in  order  to  prevent  infection.  These  may  be  applied  in  the  form  ofs 
frequent  antiseptic  vaginal  douches.  In  cases  in  which  hemorrhage  is  exces- 
sive it  is  best,  after  cleansing  the  vagina,  to  tampon  the  latter  firmly  with 
antiseptic  or  aseptic  gauze.  In  cases  also  in  which  the  abortion  proceeds 
slowly  a  tampon  is  advisable.  It  acts  both  as  a  stimulant  of  uterine  contrac- 
tion and  as  a  mechanical  obstruction  to  bleeding.  It  must  be  noted  that  in 
pregnancies  later  than  the  fourth  month  bleeding  may  goon  in  utero  in  some 
cases  even   though  a  firm  vaginal  tampon  be  in  position.     To  avoid  this  it  is 


THE   PATHOLOGY    OF  PREGNANCY.  323 

well  to  allow  the  liquor  amnii  to  escape  by  puncturing  the  amnion,  and  then  to 
introduce  the  gauze  into  the  uterus  before  tamponing  the  vagina.  The  plug 
may  be  removed  in  ten  or  twelve  hours,  when  the  complete  abortion-mass  may 
often  be  found  in  the  vagina.  If  this  is  not  the  case,  another  tampon  may 
be  introduced  for  twelve  hours  longer.  If,  however,  the  uterus  be  not  emp- 
tied, the  patient  may  be  anesthetized  and  the  mass  removed  with  fingers  and 
curet.  A  hot  intra-uterine  douche  is  then  given,  and  the  patient  kept  at  rest 
for  ten  or  twelve  days.  Many  advise  the  use  of  ergot  in  order  to  promote 
expulsion  and  to  check  hemorrhage.  In  our  opinion  this  is  an  unnecessary 
procedure.  In  diminishing  the  hemorrhage  of  abortion  it  is  not  so  satisfac- 
tory as  the  vaginal  tampon,  and  the  large  doses  necessary  are  very  apt  to 
contract  the  uterus  to  such  an  extent  that  the  os  internum  will  not  allow  the 
uterine  contents  to  pass  through  easily.  If  the  drug  be  used  at  all,  it  should 
be  given  only  in  small  doses  to  improve  the  tone  of  the  uterine  musculature,  in 
cases  in  which  it  acts  feebly,  without  producing  violent  contractions.  Quinin 
is  also  recommended  for  this  purpose. 

In  Complete  Abortion. — When  the  uterus  has  spontaneously  emptied  itself, 
the  patient  should  be  kept  in  bed  and  treated  as  she  would  be  after  labor,  not 
being  allowed  to  rise  before  the  tenth  day.  If  there  is  reason  to  suspect  that 
the  vagina  is  septic,  warm  antiseptic  douches  should  be  given  twice  daily 
for  at  least  a  week.  When  much  blood  has  been  lost,  or  the  uterus  does  not 
contract  well,  ergot  may  be  given  for  a  few  days.  Intra-uterine  douching  is 
necessary  only  when  blood-clots  tend  to  accumulate  above  the  os  internum,  or 
when  there  is  evidence  of  intra-uterine  infection  ;  it  should  be  carried  out 
only  by  means  of  a  double  catheter.  Sometimes  such  profuse  hemorrhage 
may  occur  after  a  complete  abortion  as  to  require  an  intra-uterine  or  a  vaginal 
tampon  for  twenty-four  hours  or  more. 

In  Incomplete  Abortion. — The  ordinary  practice  of  administering  ergot 
when  the  uterus  is  incompletely  emptied  cannot  be  too  strongly  condemned. 
Though  bleeding  may  be  checked  for  a  time,  the  woman  is  left  in  a  condition 
very  favorable  to  the  development  of  aftei'-troubles — e.  g.,  recurrent  hemor- 
rhage, subinvolution,  acute  or  chronic  infective  processes.  An  incomplete 
abortion-mass  is  a  foreign  body  which  should  be  removed  from  the  uterus. 
There  is  some  difference  of  opinion  as  to  whether  this  should  apply  to  a  non- 
separated  and  retained  decidua  vera.  As  nature's  method  in  spontaneous 
abortion  produces  exfoliation  and  delivery  of  the  superficial  vera,  discussion 
is  surely  needless.  There  is  no  doubt  that  retention  of  a  considerable  por- 
tion of  the  vera  may  lead  to  after-troubles  in  many  cases. 

Removal  of  the  uterine  contents  should  be  carried  out  as  a  surgical  opera- 
tion with  the  strictest  attention  to  technic.  The  patient  should  be  anes- 
thetized and  placed  in  the  lithotomy  position.  The  vulva  and  vagina  should 
be  thoroughly  cleansed,  the  bladder  and  rectum  having  been  emptied.  The 
cervix,  held  by  a  volsella,  should  be  dilated  with  a  series  of  graduated  dilata- 
tions, until  one  or  two  fingers  can  be  introduced  into  the  cavity  of  the  uterus. 
The  other  hand  presses  down  the  uterus  through  the  abdominal  wall  while 


321  AMERICAN    TEXT-BOOK   OF    OBSTETRICS. 

the  intra-uterioe  fingers  explore  the  cavity,  separating  the  abortion-remains 
from  the  wall.  These  portions  may  be  removed  in  some  eases  by  the  fingers  ; 
when  this  is  impossible,  the  curet-forceps  may  be  employed.  Small  shreds 
may  be  washed  out  with  a  stream  of  water. 

When  it  is  impossible  to  separate  all  the  tissue  from  the  wall  with  the 
fingers,  a  curet  or  curet-forceps  may  be  employed.  In  some  cases,  in  which 
the  cervix  contracts  even  after  dilatation  has  been  carried  out,  these  instru- 
ments alone  can  be  used.  In  the  fifth  or  sixth  month,  when  the  fetus  is  of 
considerable  size,  if  contraction  of  the  cervix  is  very  marked,  it  is  best  to 
dilate  as  much  as  possible,  and  then  to  introduce  a  Barnes  bag. 

After  twelve  or  fourteen  hours,  if  the  abortion  has  not  occurred,  the  uterus 
may  then  be  more  easily  emptied.  The  after-treatment  is  the  same  as  that 
already  described. 

In  Missed  Abortion. — When  this  condition  is  diagnosed,  the  uterus  should 
be  emptied.  Sometimes  the  vaginal  tampon  may  stimulate  the  uterus  to  con- 
traction. In  other  cases  the  introduction  of  a  Barnes  bag  into  the  cervix  for 
a  few  hours  may  be  necessary.  Sometimes  dilatation  may  be  carried  out,  so 
that  the  uterine  contents  may  be  removed  by  fingers,  curet,  and  curet-forceps. 
In  every  instance  the  uterus  should  be  carefully  explored  to  insure  that 
nothing  be  left  behind. 

7.  Extra-uterine  Pregnancy. 

History. — Extra-uterine  pregnancy  from  the  standpoint  of  its  etiology, 
pathology,  and  operative  treatment  has  provoked  such  numerous  discus- 
sions and  called  forth  so  many  valuable  essays  within  the  past  fifteen  or 
twenty  years  that  the  historical  side  of  the  subject  has  received  but  little 
attention.  From  this  one-sided  view  the  impression  has  arisen  in  the  minds 
of  many  practical  men  that  this  anomalous  form  of  gestation  was  almost,  if 
not  quite,  unknown  even  to  our  immediate  predecessors.  A  little  study  of  the 
medical  literature  of  the  past  four  centuries,  however,  brings  to  light  many 
classical  descriptions  of  well-recognized  eases  of  extra-uterine  pregnancy. 

Israel  Spaeh,  in  his  extensive  gynecological  work,  published  in  1597, 
figures  a  lithopedion  drawn  in  situ  upon  a  full-length  cut  of  a  woman  with 
the  belly  laid  open.  He  dedicated  to  this  calcified  fetus,  which  he  regarded 
as  a  "reversion,"  the  following  curious  epigram,  in  allusion  to  the  classical 
myth  that  after  the  flood  the  world  was  repopulated  by  the  two  survivors, 
Deucalion  and  Pyrrha,  who  walked  over  the  earth  casting  behind  them  stones 
which,  on  striking  the  ground,  became  people.  Roughly  translated  from  the 
Latin,  this  quaint  epigram  reads  as  follows  :  "Deucalion  cast  stones  behind 
him  and  thus  fashioned  our  tender  race  from  the  hard  marble.  How  comes 
it  that  now-a-days  by  a  reversal  of  things  the  tender  body  of  a  little  babe 
has  limbs  nearer  akin  to  stone?" 

We  find  many  of  the  earliest  writers  mentioning  this  form  of  fetation  as  a 
curiosity,  but  offering  no  explanation  as  to  its  cause.     One  of  the  first  and 


THE   PATHOLOGY    OF  PREGNANCY.  325 

most  natural  suggestions  was  that  the  fetus  had  died  in  utero,  and  afterward 
had  become  displaced  into  the  abdominal  cavity,  where  it  excited  suppuration 
and  thus  was  finally  discharged. 

An  important  discussion  was  called  forth  in  1669  by  the  case  of  Beuedict 
Vassal,  a  surgeon  in  Corrari,  Italy.  The  great  obstetrician  Mauriceau's  draw- 
ing (Fig.  155)  of  the  specimen  obtained  shortly  after  the  autopsy  is  remark- 
ably clear,  and  it  well  supports  his  judgment  that  this  was  not  a  tubal  preg- 
nancy as  asserted.  His  description  of  the  case  is  well  worth  quoting  even  at 
this  day  :  translated  freely,  it  is  as  follows  : 

"  History  of  a  woman  in  whose  abdomen  there  was  found,  after  death,  a 
small  fetus  about  2  J  inches  long,  together  with  a  great  quantity  of  coagulated 
blood. 

"The  history  of  this  case  deserves  to  be  carefully  considered  to  decide 
whether  the  fetus,  as  believed  by  many,  was  generated  in  the  ejaculatorv  ves- 
sel, called  the  tube  of  the  womb.  On  the  sixth  of  January,  1669,  in  the 
village  Corrari,  I  saw  in  the  hands  of  a  surgeon  named  Benedict  Vassal  a 
uterus  which  he  had  removed  a  short  time  before  from  the  body  of  a  woman 
aged  thirty-two,  who  had  died  after  three  days  of  the  most  agonizing  pains  in 
the  stomach,  from  which  she  had  fallen  into  frequent  fainting  spells  and  the 
most  violent  convulsions.  This  woman  had  borne  eleven  children  at  term, 
but  in  her  twelfth  pregnancy,  at  about  two  and  a  half  months,  the  womb 
dilated  in  the  direction  of  the  right  horn,  and,  unable  to  withstand  this  disten- 
tion, ruptured.  The  fetus  was  expelled  into  the  abdomen,  and  was  found  with 
a  great  quantity  of  coagulated  blood  among  the  intestines  of  the  mother. 
Many  physicians,  surgeons,  and  naturalists  betook  themselves  to  this  surgeon 
to  see  the  uterus  which  was  exhibited  by  him  as  a  prodigy,  as  he  insisted  that 
the  fetus  was  formed  in  the  ejaculatory  vessel,  which  Fallopius  calls  'the  trum- 
pet of  the  womb.'  They  accepted  at  once,  without  further  investigation,  that 
this  was  just  as  the  said  surgeon  claimed,  and  that  this  case  confirmed  stories 
of  a  like  nature  narrated  by  Riolanus.  However,  I  examined  the  parts  of  the 
uterus  most  carefully  and  minutely,  and  it  was  evident  to  me  that  those 
who  accepted  this  opinion  had  been  led  into  error ;  for  this  reason,  at  that 
time  I  made  a  drawing  of  the  womb  as  it  then  appeared,  and  this  is  a  more 
faithful  and  accurate  reproduction  than  that  which  this  surgeon  had  engraved 
upon  copper  after  a  month  had  elapsed,  as  the  uterus  then  retained  almost 
nothing  of  its  primitive  form,  and  was  spoiled  by  the  handling  of  a  thousand 
men  or  more  who  had  seen  the  uterus,  pulled  it,  disturbed  it,  and  turned  it 
inside  out  that  they  might  examine  it, 

"  Many  have  adduced  this  case  to  prove  to  us  that  the  testes "  [ovaries] 
"  of  women  are  full  of  little  ova  which  at  the  moment  of  coitus  free  them- 
selves and  emerge  from  the  body  proper  of  the  testes,  whence  they  are  borne 
into  the  uterus  through  the  tube,  to  serve  for  the  generation  of  the  fetus. 
They  claim  that  one  of  these  so-called  ova  had  by  chance  remained  in  the 
tube  of  this  woman,  instead  of  passing  forward  into  the  uterus,  and  that  this 
was  the  cause  of  her  death. 


326 


AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 


"Regner  de  Graaf  among  others  holds  this  opinion,  for  the  confirmation 
of  which  lie  brings  forward  the  figure  of  this  uterus,  which  the  surgeon  of 
whom  I  have  spoken  had  already  given  to  the  public;  as  one  finds  it  on  the 
260th  page  of  his  book  on  the  '  Generative  Organs  of  Women.'     Any  one 


Fig.  155. — Case  of  extra-uterine  pregnancy  figured  by  Mauriceau,  redrawn,  but  practically  unchanged. 
The  fetus  is  here  shown  attached  to  the  sac,  which  was  not  the  case  in  his  figure.  The  distinct  neck 
between  the  sac  and  the  uterus  is  evident ;  the  round  ligament  comes  out  of  the  under  surface  of  the  sac 
more  toward  its  outer  pole.   The  relations  of  a  normal  uterus  are  indicated  by  Mauriceau  in  dotted  lines. 

who  will  examine,  carefully  and  without  prejudice,  the  following  figure,  which 
is  most  faithful  and  faultless,  and  at  the  same  time  look  into  our  reasons,  will 
find  that  we  have  given  another  demonstration  which  we  believe  to  be  the 
true  explanation." 

Mauriceau  with  great  insight  then  cites  the  anatomical  relation  of  the 
round  ligaments  to  the  body  of  the  uterus  as  substantiating  his  view  of  the 
case.  He  says,  "  Behold  how  clearly  I  demonstrate  that  this  part  in  which 
the  child  was  contained  was  a  portion  of  the  body  proper  of  the  womb,  and 
not  the  tuba  uteri na,  and  this  because  the  round  ligament  is  constantly 
attached  directly  to  the  lateral  wall  of  the  body  of  the  womb,  called  the 
cornu,  and  at  this  place  it  becomes  fused  with  the  substance  of  the  womb.  It 
is  therefore  certain  that  the  part  where  the  ligament  ended  (Fig.  155),  and  at 
which  it  was  strongly  attached  on  the  right  side,  where  the  malformation 
existed,  was  a  portion  of  the  womb  itself;  consequently  the  child  was  engen- 
dered in  a  part  of  the  womb  that  was  elongated." 

It  is  interesting  in  this  connection  to  note  that  Mauriceau,  in  this  differen- 
tial diagnosis,  anticipated  some  of  the  results  of  our  latest  investigations  con- 
cerning the  differences  between  tubal,  cornual,  and  interstitial  pregnancy  and 
pregnancy  in  a  rudimentary  horn.    From  the  above  it  is  evident  that  Mauri- 


THE  PATHOLOGY   OF  PREGNANCY.  327 

ceau  was  positive  that  impregnation  had  not  occurred  in  the  Fallopian  tube, 
but  in  one  cornu  of  the  uterus,  and  that  the  ovum  had  developed  as  a  hernia 
from  the  uterus.  I  find  that  Regner  de  Graaf,  just  as  Mauriceau  states, 
accepted  the  view  of  Vassal,  and  in  his  description  of  the  Fallopian  tube 
reports  the  case  and  reproduces  the  figure  from  the  copper  plate  which  Mauri- 
ceau condemns.  De  Graaf  believed  that  this  was  a  case  substantiating  his 
own  theory  regarding  the  function  of  the  ovaries  and  the  Fallopian  tube.    He 


Fig.  156. — Reduced  figure  of  Deutsch's  case  of  abdominal  pregnancy  (an  account  of  which  was  published 
in  1799  with  life-size  copper-plate  engravings). 

says,  "We  judge  that  the  tubes  called  Fallopian  in  women  and  in  every  kind 
of  female  are  true  vasa  deferentia,  or,  if  you  prefer,  oviducts,  inasmuch  as  the 
ova  are  transmitted  through  them  to  the  uterus."  He  further  says,  "  The 
tube  or  horn  [Fallopian  tube]  of  the  womb  is  dilated  and  affected  by  semen 
corrupted  there  and  seeking  an  outlet ;  but  it  is  remarkable  that  the  male 
semen  should  reach  that  point  and  that  a  fetus  should  have  been  conceived 
there,  as  is  proved  by  histories." 

De  Graaf  believed  that  the  ova  were  fertilized  in  the  ovaries  and  that  they 
were  then  carried  downward  into  the  uterus,  where  they  remained  until  the 
full  term  of  gestation  was  completed.  He  does  not  offer  any  explanation  of 
the  arrest  and  development  of  the  ovum  in  the  tube  ;  on  the  contrary,  he  dis- 
tinctly states  that  he  does  not  know  why  it  occurs.  He  recognized,  however, 
the  dangers  of  this  anomalous  pregnancy,  as  indicated  by  the  following  state- 


328  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

ruent :  "The  ovum  already  fertilized  is  detained  in  its  transit  in  the  tubes, 
and  by  its  increase  in  size  brings  death  to  the  mother."  In  his  critical  remarks 
upon  Vassal's  case  he  says  :  "  And  from  this  our  opinion  it  is  not  difficult  to 
explain  how  a  fetus  occasionally  develops  in  the  abdominal  cavity  among  the 
intestines,  inasmuch  as  the  ova  already  impregnated  fall  from  the  testes" 
[ovaries]  "  outside  the  cavity  of  the  tubes  and  are  nourished  by  the  neigh- 
boring parts." 

From  these  references  to  the  earlier  literature  it  will  be  seen  that  ectopic 
gestation  was  clearly  recognized,  its  symptoms  graphically  described,  and  the 
theories  advanced  those  that  are  accepted  by  many  writers  of  the  present  day. 

Numerous  other  contributions  are  found  in  the  literature  of  this  subject, 
following  De  Graaf  and  Mauriceau,  one  of  the  most  interesting  being  figured 
in  the  obstetrical  work  of  Peter  Dionis  of  Paris,  published  in  the  early  part 
of  the  eighteenth  century. 

Even  so  early  as  1741,  Bianchi  constructed  an  elaborate  classification  of  the 
forms  of  extra-uterine  pregnancy,  which  was  simplified  by  Boehmer  in  1752, 
who  described  three  forms — "gestatio  ovarica,"  "gestatio  tubaria,"  and  "ges- 
tatio  abdominalis."  From  the  time  of  Boehmer  a  period  of  forty-nine  years 
intervened  in  which  this  classification  remained  practically  unchanged.  In 
1801,  Schmidt  described  the  interstitial  form  of  ectopic  gestation,  and  with 
this  addition  Boehmer's  classification  must  practically  be  accepted  even  at  the 
present  clay,  with  the  exception  of  a  primary  abdominal  form. 

Etiology. — No  entirely  satisfactory  conclusions  have  yet  been  reached 
regarding  the  cause  of  this  anomalous  form  of  pregnancy.  Among  many 
theories  none  have  been  demonstrated.  One  great  difficulty  lies  in  the  fact 
that  it  has  not  yet  been  determined  at  what  point  in  the  female  genital  tract 
normal  impregnation  of  the  ovum  takes  place,  and  until  this  question  is 
settled  the  primary  question,  t  whether  extra-uterine  fetation  is  an  abnormal 
ectopic  impregnation  or  is  simply  a  detained  impregnated  ovum,  must  remain 
unanswered.  Many  claim  that  the  seat  of  coalescence  of  the  male  and  the 
female  elements  is  normally  in  the  Fallopian  tube.  If  this  claim  is  admitted, 
it  can  readily  be  seen  how  a  variety  of  causes  might  operate  to  detain  the  ovum 
in  the  tube,  where  it  may  continue  to  develop  extra-uterine.  Chief  among  the 
causes  ascribed  a  few  years  ago,  at  the  revival  of  this  subject,  was  the  loss  of 
the  tubal  ciliated  epithelium,  which  would  manifestly  conspire  to  prevent  the 
ovum  from  being  carried  on  down  into  the  uterus ;  other  causes  cited  have 
been  flexions  of  the  tube,  dilatations  and  diverticula,  constrictions  from  inflam- 
matory changes,  and  polypi  in  the  tube,  closing  its  lumen  like  a  valve. 

While  a  variety  of  causes  may  operate,  it  is  most  probable,  from  the 
frequencv  with  which  old  inflammatory  disease  is  found  coexisting  on 
the  other  side,  that  most  cases  of  tubal  gestation  arise  from  ileus  of  the 
tube,  resulting  in  an  inability  to  transmit  the  contents  of  the  tube,  due  to 
adhesions.  An  important  cause,  operating  in  cases  where  the  pregnancy  is 
toward  the  outer  end  of  the  tube,  is  the  presence  of  a  diverticulum,  as  pointed 
out  bv  J.  W.  Williams  and  others. 


THE   PATHOLOGY   OF  PREGNANCY.  329 

Classification :  Primary  Forms. — The  primary  forms  of  extra-uterine  preg- . 
nancy  are  classified  as  follows  : 

Tubo-uterine  or  interstitial. 


1.  Tubal:    [   Y^u'  2.  Ovarian. 

Ampullar. 

[_  Fimbria  tubo-ovarica. 
Secondary  forms  are  derived  from  the  primary,  as  follows : 

,  x  -n         *  ( Uterine ;  M  u    „  (1  ( Tubo-ovarian ; 

(a)  From  the        I  g      d  „'  (o)  From  the         I  Abdomina, 

interstitial :  |  Abdomimih  ampullar  :   |  BrQad  ^^ 

(6)  From  the        f  Abdominal ;  (d)  From  the        J  Abdominal ; 

isthmial :     \  Broad  ligament.  ovarian  :       (  Tubo-ovarian. 

In  tubal  pregnancy,  when  the  fertilized  ovum  develops  out  near  the  fimbri- 
ated extremity  of  the  tube  it  is  called  ampullar ;  at  the  inner  portion  of  the 
tube  it  is  called  isthmial;  while  in  that  part  of  the  tube  which  traverses  the 
uterine  wall  it  is  designated  interstitial  or  tubo-uterine.  It  is  in  the  latter  form 
that  the  term  extra-uterine  pregnancy  becomes  a  misnomer,  as  the  conception 
is  not,  strictly  speaking,  extra-uterine,  being  enclosed  in  the  wall  of  the  uterus, 
although  outside  its  cavity.  For  this  reason  Mr.  Tait  suggested  the  term 
ectopic  gestation.  Many  writers,  more  pi'actical  than  scientific,  misled  by 
Mr.  Tait's  dogmatism,  go  so  far  as  to  hold  that  there  is  but  one  form  of 
ectopic  gestation — namely,  the  tubal — and  so  able  a  pathologist  as  Bland 
Sutton  gives  them  countenance  by  his  denial  of  the  ovarian  and  abdominal 
forms,  as  he  considers  the  cases  which  have  been  reported  do  not  sufficiently 
demonstrate  their  existence.  Xo  criticism,  however,  has  yet  succeeded  in 
destroying  the  claims  of  cases  of  Leopold,  Patenko,  and  Martin,  which  we 
must  accept  as  primarily  ovarian.  In  Leopold's  case  the  patient  was  operated 
upon  for  a  pelvic  tumor  of  twenty-five  years'  standing  that  proved  to  be  an 
ovarian  tumor  containing  a  lithopedion.  In  the  walls  of  the  tumor  ovarian 
stroma  was  clearly  demonstrated.  Patenko's  case  is  even  more  striking.  The 
right  ovary  was  the  size  of  a  hen's  egg,  and  it  contained  a  cyst  with  smooth 
walls  in  which  was  found  a  yellow  body,  the  size  of  a  hazel-nut,  composed  of 
cylindrical  and  flat  bones.  These  bones,  which  were  submitted  to  a  careful 
microscopical  examination,  were  found  to  be  fetal  in  origin  and  not  the  product 
of  a  dermoid  cyst.  The  enveloping  wall  contained  corpora  lutea  and  follicles. 
The  tube  of  the  affected  side  had  no  adventitious  connection  with  the  ovary, 
and  its  fimbriated  extremity  was  entirely  free,  although  the  internal  ostium 
was  closed  and  some  of  the  fimbria?  were  gone.  Opponents  of  the  theory  of 
ovarian  pregnancy  take  exception  to  this  case,  claiming  that  the  gestation  was 
primarily  tubal,  and  that  a  so-called  "  tubal  abortion  "  had  occurred  into  the 
ovary,  and  that  later  the  ovary  and  the  tube  had  become  detached  from  each 
other  ! 

Martin  of  Berlin  reports  two  cases  which  he  believes  are  examjjles  of 
undoubted  primary  ovarian  pregnancy.  In  these  cases  the  gestation-sac  was 
situated  entirely  within  the  ovary,  the  fimbriated  extremity  of  the  tube  being 
intact.     As  an  explanation  of  ovarian  pregnancy  Martin  advances  the  very 


330  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

natural  suggestion  that  the  spermatozoon  finds  its  way  through  the  fimbriated 
extremity  of  the  tube  into  one  of  the  small  recently-ruptured  cysts  so  fre- 
quently found  on  the  surface  of  the  ovary,  and  that  it  there  coalesces  with  the 
ovum. 

Too  few  observations  have  yet  been  made  to  prove  the  possibility  of  pri- 
mary abdominal  pregnancy,  although  the  case  of  Schlectendahl  is  difficult  to 
explain  upon  any  other  hypothesis.  In  this  case  a  fetus  measuring  15  centi- 
meters (6  inches)  in  length  was  found  attached  to  the  abdominal  wall  near  the 
spleen  in  a  woman  who  had  died  of  hemorrhage.  The  gestation-sac  was  sur- 
rounded by  adherent  intestines,  and  the  uterus  and  appendages  appealed  nor- 
mal. For  the  present,  however,  only  two  primary  forms  of  ectopic  gestation 
— tubal  and  ovarian — can  positively  be  accepted.  Practically,  as  Taifc  insisted, 
tubal  pregnancy  is  the  only  primary  form  found. 

■--. 


■  s  ■■<:■ 


Fig.  157.— Prof.  August  Martin's  case  of  ovarian  pregnancy.    The  intact  tube  is  seen  lying  above  the 
ovarian  sac  containing  the  fetal  envelopes. 

Secondary  Forms. — The  secondary  forms  of  ectopic  pregnancy  are  derived 
from  the  primary.  The  tubo-uterine  or  interstitial  pregnancy  may  rupture 
into  the  uterus  and  be  followed  immediately  by  expulsion  of  the  fetus,  or  it 
may  go  on  to  full  term  and  be  delivered  in  the  natural  way.  This  mode  of 
termination,  unfortunately,  is  rarer  than  two  other  possibilities — namely,  rup- 
ture into  the  abdominal  cavity  or  rupture  into  the  broad  ligament.  In  the 
isthmial  form  of  tubal  pregnancy  the  rupture  occurs  either  into  the  abdominal 
cavity,  thus  forming  a  secondary  abdominal  pregnancy,  or  into  the  broad" 
ligament,  forming  extra-peritoneal,  broad-ligament  pregnancy.  The  ampullar 
form  of  tubal  pregnancy  gives  rise  to  secondary  tubo-ovarian,  abdominal,  or 
broad-ligament  pregnancy. 

Tubal  Pregnancy. — In  the  first  week  after  fecundation  of  the  ovum  the 
tube  begins  to  thicken,  due  chiefly  to  vascularization  without  hypertrophy  of 
the  muscular  fibres.     In  this  respect  the  tubal  envelope  differs  in  its  develop- 


THE   PATHOLOGY   OF  PREGNANCY.  331 

ment  from  that  of  the  uterine  muscle  in  normal  pregnancy.  In  the  latter  case 
there  is  hypertrophy  of  the  individual  muscle-fibres  to  eleven  times  their 
length  in  a  normal  non-pregnant  uterus ;  the  connective  tissue,  peritoneal 
covering,  blood-vessels,  and  lymphatics  being  also  increased  by  hypertrophy 
and  hyperplasia,  so  that  at  full  term  the  uterus  weighs  two  pounds  instead  of 
two  ounces,  the  weight  of  a  virginal  uterus.  The  thickening  in  the  pregnant 
Fallopian  tube  is  due  to  excessive  vascularization  with  but  slight  increase  in 
the  tissue-elements.  As  the  pregnancy  progresses  the  wall  of  the  tube  becomes 
thinned  and  stretched  until  in  some  cases  it  appears  as  a  thin  transparent  mem- 
brane composed  only  of  an  attenuated  stratum  of  muscle  covered  with  peritoneum. 

The  development  of  the  fetal  membranes  derived  from  the  ovum,  with  the 
exception  of  the  placenta,  is  the  same  as  in  intra-uterine  pregnancy.  Nor- 
mally, the  placenta  is  derived  about  equally  from  the  decidua  serotina  of  the 
uterus  and  the  chorion  frondosum  of  the  ovum.  In  tubal  pregnancy  Bland 
Sutton  holds  that  the  placenta  is  largely  fetal  in  its  origin.  As  the  embryo 
increases  in  size  and  the  walls  of  the  tube  become  stretched,  the  plica?  in  the 
mucous  membrane  lose  their  characteristic  appearance  and  are  gradually 
smoothed  out.  During  the  first  four  to  six  weeks  the  abdominal  ostium  of 
the  tube  becomes  hermetically  sealed.  Until  the  fetal  membranes  are  well 
formed  the  life  of  the  fetus  is  in  constant  jeopardy,  as  the  chorionic  villi  have 
but  a  feeble  hold  upon  their  points  of  attachment  to  the  tube  and  may  easily 
be  dislodged.  This  termination  is  most  favorable  from  the  first  to  the  third 
week  of  the  pregnancy,  and  it  may  be  so  harmless  as  to  give  rise  to  no  serious 
discomfort. 

An  apoplectic  ovum  thus  detached  appears  as  a  lump  of  coagulum, 
and  unless  carefully  examined  its  true  character  may  be  overlooked.  Such 
bodies,  known  as  "  tubal  moles,"  are  always  products  of  an  ectopic  preg- 
nancy. As  the  pregnancy  advances  the  formation  of  the  tubal  mole  is 
attended  with  much  greater  danger,  as  the  accompanying  hemorrhage 
often  causes  rupture  of  the  tube,  followed  by  rapid  death  of  the  mother. 
These  moles,  if  recent  in  origin,  contain  the  embryo  and  its  mem- 
branes. The  essential  diagnostic  point  is  the  discovery  of  chorionic  villi  or 
of  the  embryo  itself.  If  extruded  into  the  abdominal  cavity  or  into  the  broad 
ligament  the  mole  loses  its  characteristic  appearance  and  soon  becomes  envel- 
oped in  a  yellowish  coat  of  fibrin,  and  there  may  be  such  complete  disinte- 
gration of  the  fetal  tissues  as  entirely  to  obliterate  its  embryonic  characteristics. 
The  villi,  however,  are  most  persistent,  and  they  may  be  found  after  the  other 
evidences  of  their  origin  have  disappeared.  These  villi  have  the  same  appear- 
ance under  the  microscope  as  those  of  normal  pregnancy. 

If  the  ovum  continues  to  grow,  the  point  at  which  the  placenta  is  attached 
is  of  the  greatest  importance  to  the  mother,  as  upon  this  largely  depends  her 
chance  for  life  in  case  of  rupture.  If  the  placenta  is  implanted  on  the  superior 
wall  of  the  tube,  the  mother  is  in  constant  peril,  as  rupture  here  may  be  fol- 
lowed by  frightful  hemorrhage,  the  lacerated  or  detached  placenta  having  no 
counter-pressure  to  control  its  bleeding,  as  is  the  case  when  it  is  attached  to 


332 


AMERICA X    TEXT-BOOK    OF    OBSTETRICS. 


the  floor  of  the  tube.  For  this  reason  many  surgeons  claim  that  this  termi- 
nation is  invariably  fatal.  If  the  placenta  is  implanted  on  the  floor  of  the 
tube,  the  chances  of  rupture  are  not  necessarily  decreased,  but  the  dangers 
attending  this  accident  are  far  less  to  the  mother.  In  this  position  the  pla- 
centa is  pushed  downward  against  the  resisting  pelvic  floor,  insinuating  itself 
between  the  layers  of  the  broad  ligament.  If  the  embryo  is  extruded  through 
the  upper  wall  of  the  tube,  the  placenta  may  still  retain  a  firm  attachment  and 
only  slight  hemorrhage  follow,  and  the  immediate  clanger  be  escaped  in  this 
way.  Occasionally  the  ovum  is  lightly  attached  in  the  ampullar  extremity  of 
the  tube,  and  is  extruded  into  the  abdominal  cavity  without  rupture  of  the 
tubal  walls.  This  extrusion  is  known  as  a  "tubal  abortion."  As  evidence  of 
this  the  fimbriated  extremity  of  the  tube  is  found  enlarged  and  patulous,  and 
there  is  free  blood  in  the  abdominal  cavity,  in  which  the  tubal  mole  may  be 
found  if  the  abortion  is  recent. 

Tubo-uterine  or  Interstitial  Gestation. — The  history  of  the  embryonic 
development  in  this  type  of  ectopic  gestation  differs  from  the  tubal  proper  on 

account  of  its  difference  in  envi- 
ronment. Here  the  muscular 
fibres  of  the  uterus  undergo  the 
same  changes  as  in  normal  preg- 
nancy. Rupture  is  almost  inev- 
itable, but  it  does  not  occur  so 
early  as  in  the  tubal  variety,  on 
account  of  the  greater  thickness 
of  the  walls  surrounding  the  ges- 
tation-sac. Hecker  collected 
twenty-six  cases  in  which  rupture 
occurred  before  the  sixth  month. 
The  fetus  occasionally  escapes  into 
the  uterus,  and  it  is  either  ex- 
pelled at  once  or  it  goes  on  to 
regular  term  and  is  born  in  the 
natural  way.  Rupture  occurs 
most  frequently  into  the  abdom- 
inal cavity,  and  in  such  cases  the 
hemorrhage  is  profuse  and  usually  terminates  the  patient's  life  in  a  short  time. 
Interstitial  pregnancy  is  rarely  recognized  before  rupture. 

Rupture  of  the  Sac. — The  time  of  rupture  of  the  sac  depends  upon  its 
location  and,  to  a  certain  extent,  upon  the  attachment  of  the  placenta.  In 
tubal  pregnancv  primary  rupture  occurs  usually  between  the  second  and  the 
fourteenth  week.  When  the  placenta  is  implanted  on  the  floor  of  the  tube,  the 
probability  is  that  the  rupture  will  not  take  place  so  early  as  when  it  is  situated 
on  the  superior  wall.  The  causes  of  rupture  are  thinning  of  the  walls  of  the 
tubes  beyond  the  limits  of  elasticity,  hemorrhage  into  the  sac,  traumatism,  and 
gradual  enlargement  of  the  embryo.     If  the  patient  survive  the  primary  rup- 


Fig.  15S.— Diagram  showing  pelvic  hematocele  poste- 
rior to  the  uterus,  which  is  crowded  forward  with  the 
bladder  behind  the  symphysis  pubis,  while  the  rectum 
is  compressed  behind  against  the  sacrum  (Skene). 


THE  PATHOLOGY   OF   PREGNANCY.  333 

ture,  the  fetus  may  still  continue  to  develop,  either  burrowing  downward 
between  the  layers  of  the  broad  ligament  or  growing  upward  into  the  peri- 
toneal cavity  among  the  intestines.  The  injury  to  the  placenta  is  much  less 
when  it  is  situated  on  the  pelvic  floor,  as  the  displacement  is  not  so  marked, 
the  hemorrhage  is  not  so  profuse,  and  consecpiently  the  lives  of  the  fetus  and 
the  mother  are  in  less  jeopardy  at  the  time  of  rupture.  If  blood  is  poured 
into  the  peritoneal  cavity,  it  will  usually  be  absorbed ;  if  the  collection  of 
blood  occurs  between  the  layers  of  the  broad  ligament,  it  constitutes  pelvic 
hematocele  (Fig.  158).  When  the  fetus  becomes  intra-ligamentary  and  con- 
tinues its  development  in  that  position,  it  is  known  as  broad-ligament  gesta- 
tion. After  the  twelfth  week  the  sac  is  liable  to  secondary  rupture  at  any 
time  up  to  term.  Here  again  the  situation  of  the  placenta  is  of  the  same 
importance  in  the  prognosis  as  in  the  primary  rupture. 


Fig.  159.— Ruptured  left  tubal  pregnancy,  fetus  still  attached  and  lying  within  the  pelvis.  Hydrosal- 
pinx and  adhesions  on  the  right  side.  Uterus  displaced  toward  the  right  by  the  sac :  u  is  the  fundus 
uteri ;  r,  the  rectum ;  (,  the  right  closed  tube  ;  /,  the  fetus ;  and  s,  the  ruptured  extra-uterine  sac. 

The  Fetus. — The  question  as  to  the  possibility  of  life  for  the  fetus  is  influ- 
enced by  the  location  of  the  pregnancy.  In  the  tubal  variety  the  most  favor- 
able attachment  of  the  placenta  is  on  the  floor  of  the  Fallopian  tube,  as  there 
may  be  slight  if  any  disturbance  of  the  fetal  circulation  if  the  rupture  be  in 
the  superior  wall  of  the  tube,  when  the  child  may  go  on  to  full  term  (Figs. 
159,  160).  Even,  however,  if  the  ectopic  fetus  be  delivered  alive,  it  is  often 
deformed  and  puny  and  rarely  lives  more  than  a  few  days.  For  this  reason 
its  life  should  be  but  little  regarded  in  the  treatment  of  ectopic  gestation. 

The  disposal  which  nature  makes  of  the  fetus  in  case  the  mother  survives 
the  rupture  is  also  of  considerable  interest.  The  dead  embryo  lying  free  in 
the  abdominal  cavity  may  be  completely  absorbed  up  to  the  second  month ; 
after  that  period  it  either  undergoes  mummification,  calcification,  or  is  con- 
verted into  adipocere,  or  decomposes.  Mummification  is  analogous  to  the 
change  which  bodies  undergo  in  a  dry  atmosphere.  A  mummified  fetus  in 
its  general  appearance  closely  resembles  bodies  found  in  arid  regions  buried  in 


334 


[3IEBICAN    TEXT- BOOK    OF    OBSTETRICS. 


dry  soil  or  in  sand  or  exposed  to  the  air.  The  fluid  constituents  of  the  extra- 
uterine gestation  are  absorbed,  and  the  soft  tissues  become  leathery  or  parch- 
ment like.  In  other  cases  the  fatty  elements  are  converted  into  adipocere  or 
into  ammoniacal  soap  in  the  presence  of  ammonia  formed  by  the  decom- 
position of  the  tissues.  Either  the  mummified  or  the  adipocere  fetus  may  still 
undergo  further  change  and  become  partially  or  wholly  calcified.  This  pro- 
cess is  not  entirely  confined  to  the  superficial  parts,  as  there  have  been 
described  a  number  of  specimens  which  exhibited  the  saponaceous  or  the 
mummification  process  on  the  exterior  while  the  internal  organs  were  calcified. 
A  fetus  which  has  undergone  calcification  is  known  as  a  lithopedion. 

The  fetal  mass  may  remain  indefinitely  in  the  abdominal  cavity  without 
giving  rise  to  any  discomfort  to  the  mother.     Cases  are  reported  in  which 


Fig.  160.— Cornual  pregnancy.    In  this  case  rupture  occurred  in  the  right  undeveloped  cornu  of  a 
bicornute  uterus  (from  a  specimen  presented  to  the  writer  by  Dr.  Watson  of  Baltimore). 

such  bodies  have  stayed  for  ten  and  fifteen  years,  in  one  instance  for  fifty-four 
years,  in  the  pelvis  without  giving  rise  to  serious  trouble.  On  account  of  the 
close  anatomical  relation  between  the  gestation-sac  and  the  rectum  and  intestines 
a  slight  rupture  of  the  intervening  walls  may  occur  at  any  time,  or  a  diapedesis 
may  take  place  and  pyogenic  organisms  gain  access  into  the  sac  and  induce 
suppuration.  The  fetus  is  then  converted  into  a  putrid  mass,  which  may  be 
discharged  into  the  rectum,  the  vagina,  or  the  bladder.  Occasionally  the  sup- 
purating mass  ruptures  at  some  point  on  the  anterior  abdominal  wall  even  so 
high  as  the  umbilicus.  The  latter  termination  is  frequently  noted  in  the  older 
medical  literature. 

Symptoms. — All  the  symptoms  characteristic  of  normal  pregnancy  may  be 
present.  Frequently,  however,  the  subjective  symptoms  are  entirely  absent, 
and  the  patient  may  be  quite  unconscious  of  her  condition.     The  increase  in 


THE  PATHOLOGY  OF  PREGNANCY.  335 

the  areolar  circle  around  the  nipple  and  other  mammary  changes,  the  gastric 
disturbance,  pain  on  the  affected  side,  associated  with  amenorrhea,  are  the  most 
characteristic  symptoms.  Too  much  stress,  however,  must  not  be  laid  upon 
the  absence  of  the  menstrual  flow,  as  it  is  subject  to  the  greatest  variations.  In 
some  cases  instead  of  amenorrhea  there  will  be  profuse  metrostaxis  with  the 
expulsion  of  small  bits  of  decidua. 

It  is  of  importance  not  to  confuse  the  decidua  of  ectopic  pregnancy  with 
that  of  membranous  dysmenorrhea.  In  the  latter  condition  the  decidua  is 
usually  expelled  in  small  pieces  and  rarely  as  a  cast  of  the  interior  of  the 
uterus.  When  floated  out  in  water  numerous  delicate  velamentous  processes 
are  seen.  This  membrane  is  rarely  more  than  one  or  two  lines  in  thickness, 
and  it  is  usually  very  friable.  The  decidua  of  ectopic  pregnancy  is  much 
thicker,  varying  from  5  to  20  millimeters  (^- to  finch);  it  is  much  less  fri- 
able, the  uterine  surface  being  covered  with  a  thick,  shaggy,  villous  coat,  and 
instead  of  small  bits  it  is  usually  expelled  in  large  pieces  or  as  a  complete  cast 
of  the  interior  of  the  uterus.  Pain  is  variable,  in  some  cases  being  almost 
constant,  in  other  cases  absent.  The  character  of  the  pain  before  rupture 
may  be  sharp  and  lancinating,  or  there  may  be  dull  and  heavy  aching.  The 
statement  of  the  patient  that  she  considers  herself  pregnant  is  of  some  value, 
as  that  ill-defined  sense  upon  which  she  bases  her  opinion  may  be  the  only 
subjective  indication  of  her  condition.  The  appearance  of  the  external  geni- 
talia may  be  the  same  as  in  normal  pregnancy.  Under  these  circumstances 
the  vaginal  mucous  membrane  appears  purplish  in  hue,  the  cervix  is  soft,  the 
os  uteri  is  usually  closed  with  a  plug  of  mucus,  and  the  uterus,  instead  of 
its  pyriform  shape,  is  now  globular  and  enlarged  to  the  size  of  a  one-month 
pregnancy. 

If  an  examination  be  made  before  rupture,  the  Fallopian  tube  of  one 
side  will  be  found  enlarged,  and  if  far  advanced  the  uterus  will  be  forced 
from  its  position  in  the  median  line  by  the  growth  of  the  tumor.  If  the 
pregnancy  is  advanced  to  the  third  or  the  fourth  month,  a  circumscribed 
tumor,  well  defined  as  an  area  of  dulness  on  the  anterior  abdominal  wall,  may 
be  outlined  by  percussion.  Vaginal  examination  reveals  this  tumor  lateral 
and  posterior  to  the  uterus,  with  a  well-marked  sulcus  between  it  and  the 
uterus.  Unfortunately,  it  is  only  in  the  rarer  instances  that  a  physician  is 
called  before  rupture  occurs,  when,  unless  he  is  a  skilful  specialist,  the  prob- 
abilities are  that  ectopic  gestation  will  not  be  suspected.  The  growth  of  the 
tumor  may  give  rise  to  pressure-symptoms,  such  as  constipation  and  dysuria, 
but  the}-  are  of  little  special  significance,  as  any  pelvic  tumor  may  be  attended 
with  similar  disturbances. 

Rupture. — The  symptoms  of  rupture  are  very  characteristic,  and  they 
usually  are  so  definite  as  to  cause  little  doubt  in  diagnosis.  A  patient  pre- 
viously healthy  or  only  slightly  complaining  is  suddenly  seized  with  severe 
abdominal  pains,  sharp  or  lancinating,  cutting  or  agonizing.  The  attack  in 
many  instances  cannot  be  ascribed  to  external  violence  or  to  undue  exertion  on 
the  part  of  the  patient,  as  she  may  be  in  the  midst  of  light  household  work, 


336  AMEBIC  AX   TEXT-BOOK   OF   OBSTETBICS. 

or  walking  on  the  street,  or  even  be  in  bed  when  the  rupture  occurs.  Previous 
to  the  attack  she  may  have  had  no  discomfort  or  only  the  slight  disturbances 
of  pregnancy.  If  the  hemorrhage  is  extensive  she  may  fall  unconscious  as  if 
struck  a  blow.  The  pulse,  at  first  rapid,  soon  becomes  almost  or  quite  imper- 
ceptible ;  the  respiration  is  quickened,  then  becomes  jerky,  and  finally  the  air- 
hunger  so  characteristic  of  severe  hemorrhage  becomes  pronounced ;  vertigo, 
nausea,  and  vomiting  are  present.  The  symptoms  soon  merge  into  those  of 
profound  shock,  the  extremities  being  cold  and  clammy,  the  skin  pale,  the 
conjunctiva?  pearly,  and  the  lines  about  the  mouth  drawn.  If  the  patient  is 
conscious  and  is  able  to  talk,  she  will  usually  complain  of  intense  abdominal 
pain.  Death  may  follow  soon  after  intraperitoneal  rupture,  or  it  may  be 
delaved  for  a  dav  or  even  longer.  In  some  instances  the  bleeding  ceases  for 
a  short  time  and  is  followed  by  gradual  improvement  in  symptoms,  but  it 
again  begins  a  few  hours  or  some  days  later,  and  the  patient  survives  only 
a  few  minutes. 

In  extraperitoneal  hemorrhage  from  rupture  into  the  broad  ligament  the 
symptoms  may  not  be  so  urgent.  The  initial  attack  in  both  instances  is  simi- 
lar, as  the  peculiar  sharp  pain  at  the  onset  is  due  to  rupture  of  the  tube.  The 
blood  as  it  accumulates  usually  checks  the  hemorrhage  by  its  own  pressure, 
and  the  patient  may  have  no  further  trouble.  If  the  embryo  dies  at  the  time 
of  primary  rupture  into  the  broad  ligament,  no  further  discomfort  is  felt,  as  a 
rule,  as  a  harmless  hematocele  is  all  that  remains.  Unfortunately,  in  many 
instances  this  is  not  the  termination,  and  the  fetus  continues  to  develop,  and 
sooner  or  later  a  secondary  rupture  occurs,  attended  by  the  same  symptoms  as 
the  primary  rupture. 

In  the  rarer  cases,  which  go  on  for  nine  months,  labor-like  pains  come  on 
and  closelv  simulate  those  of  normal  parturition.  These  pains  may  continue 
for  hours  or  even  for  davs,  and  then  cease.  The  escape  of  blood  and  of  por- 
tions of  the  decidua  occurs  in  a  majority  of  cases  at  this  time,  and  may  mis- 
lead the  attending  physician  into  the  diagnosis  of  abortion  if  the  constitutional 
symptoms  are  not  urgent.  The  subjective  symptoms  of  pregnancy  are  almost 
alwavs  present  in  such  advanced  cases.  The  fetal  movements  may  have  been 
so  much  on  one  side  as  to  call  the  mother's  attention  to  this  phenomenon. 
The  fetal  heart-sounds  are  distinct,  being  heard  with  unusual  clearness. 

In  cases  surviving  the  rupture  the  sharp  labor-like  pains  gradually  sub- 
side, the  secretion  in  the  breasts  disappears,  the  tumor  decreases  rapidly  in 
size,  and  as  soon  as  the  patient  recovers  from  the  shock  and  loss  of  blood  she 
may  regain  her  health.  It  is  in  these  cases  that  absorption  or  one  of  the  other 
changes  that  render  the  fetal  body  innocuous  takes  place.  Infection  of  the 
incarcerated  fetal  mass  may  occur  at  any  time,  even  years  after  the  death  of 
the  embryo,  followed  by  a  train  of  symptoms  similar  to  those  attending  pus- 
formation  from  other  causes. 

Diagnosis. — The  history,  if  carefully  reviewed,  often  directs  attention 
strongly  toward  ectopic  gestation.  The  pregnancy  usually  occurs  in  a  mul- 
tipara some  vears  after  the  birth  of  the  last  child,  although  it  may  follow 


THE  PATHOLOGY   OF  PREGNANCY.  337 

shortly.  There  may  have  been  an  intervening  attack  of  acute  inflammation 
of  the  tube  or  of  pelvic  peritonitis.  This  is  strongly  insisted  upon  by  those 
who  advocate  the  theory  that  tubal  gestation  is  due  to  an  old  inflammatory 
process  which  has  changed  the  normal  histology  of  the  tube. 

A  characteristic  history  is  as  follows :  A  woman  who  has  borne  one  or 
more  children,  after  an  interval  of  from  five  to  twenty  years  of  sterility 
observes  symptoms  of  another  pregnancy.  Her  menses,  which  have  been 
regular,  cease,  and  the  morning  nausea,  pain  in  the  breasts,  darkening  of 
the  areola,  and  other  symptoms  characteristic  of  her  former  pregnancies 
appear.  In  addition  to  these  symptoms,  she  has  in  one  ovarian  region  dull 
pain,  at  times  so  severe  as  to  cause  her  to  seek  the  advice  of  her  phy- 
sician. This  pain  may  continue  until  it  culminates  in  the  acute  paroxysms 
caused  by  rupture,  or  it  may  cease,  and  not  be  noticed  again  until  the  rupture 
occurs.     The  most  characteristic  symptom  of  all  is  the  sudden  sharp  pain  of 


Fig.  161.— Diagrammatic  sketch  showing  relations  of  an  unruptured  sac  (s)  to  uterus  (u),  round  ligament 
(ri),  and  bladder  (6).    The  numerous  adhesions  are  suggestive  as  to  the  etiology. 

the  rupture.  If  followed  by  a  marked  anemia  it  is  still  more  decisive.  The 
bimanual  examination,  taken  in  conjunction  with  this  history,  points  with 
absolute  certainty  to  the  nature  of  the  pregnancy,  and  the  diagnosis  is  com- 
paratively simple.  In  the  atypical  cases,  on  the  contrary,  a  positive  diagnosis 
is  often  difficult  or  even  impossible. 

In  the  normal  uterine  pregnancy,  as  the  embryo  develops  the  uterus  is  dis- 
tended equally  in  all  directions,  but  occasionally  the  ovum  develops  in  one 
corner,  distending  the  uterus  on  that  side,  which  may  prove  misleading.  In 
pregnancy  occurring  in  the  rudimentary  horn  of  a  bicornute  uterus  the  symp- 
toms are  so  nearly  alike  that  a  differential  diagnosis  is  not  likely  to  be  made. 

Kussmaul  collected  thirteen  cases  of  pregnancy  in  rudimentary  coruna,  the 
majority  of  which  had  been  reported  as  tubal  pregnancies.  If  an  exploratory 
section  be  performed  in  these  doubtful  cases,  the  anatomical  points  insisted 
upon  by  Mauriceau  are  of  the  greatest  value  in  making  a  differential  diagnosis. 


338  AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 

They  are  as  follows :  In  cornual  pregnancy  the  round  ligament  is  situated 
anterior  to  the  outer  side  of  the  gestation-sac.  In  tubal  pregnancy  the  round 
ligament  is  situated  on  the  uterine  side  (Figs.  160,  161). 

Pregnancy  occurring  in  one  horn  of  a  well-developed  bicornute  uterus  may 
go  to  term  and  give  rise  to  no  untoward  symptoms.  A  pregnant  uterus  devi- 
ated to  one  side  by  a  myoma  may  be  mistaken  for  ectopic  gestation.  The  diag- 
nosis, however,  can  usually  be  made  if  the  examination  is  conducted  under 
anesthesia,  as  it  will  be  found  that  the  tumor  varies  its  position  with  that  of 
the  enlarged  uterus,  and  is  directly  continuous  with  it,  in  addition  to  being 
densely  hard.  The  question  of  interstitial  pregnane}'  naturally  arises  in  these 
cases,  and  if  the  character  of  the  tumor  cannot  be  recognized  at  the  first  exam- 
ination, the  patient's  symptoms  should  be  observed  carefully,  and  she  should  be 
examined  again  later  to  decide  whether  there  is  any  increase  in  the  size  of  the 
suspected  tumor.  If  there  is  a  perceptible  increase,  the  probabilities  are  that 
it  is  interstitial  pregnancy.  An  adherent  retroverted  gravid  uterus  may  also 
give  rise  to  misleading  symptoms,  such  as  sharp  pains,  obstinate  constipation, 
pelvic  pressure,  dysuria,  etc.,  but  it  is  readily  differentiated  by  a  bimanual 
rectal  examination,  if  necessary  drawing  the  uterus  down  with  traction  for- 
ceps so  that  the  fundus  may  readily  be  palpated. 

Ovarian  tumors  and  enlargements  of  the  Fallopian  tubes,  associated 
with  intra-uterine  pregnancy,  may  cause  confusion,  especially  if  the  tumor 
lateral  to  the  uterus  gives  rise  to  sharp  pain,  as  may  occur  in  pyosalpinx. 
In  such  instances  the  question  of  a  twin  pregnancy,  one  intra-uterine  and 
the  other  extra-uterine,  must  be  considered.  As  fever  accompanies  pyosal- 
pinx in  the  majority  of  cases,  it  must  carefully  be  considered  in  the  differ- 
ential diagnosis.  If  it  be  impossible  to  arrive  at  definite  conclusions  con- 
cerning the  suspected  mass,  and  the  life  of  the  patient  seems  in  peril,  an 
exploratory  celiotomy  is  justifiable,  otherwise  expectancy  is  the  safer  course. 
Occasionally  a  pedunculated  ovarian  cyst  becomes  strangulated  by  axial  rota- 
tion :  such  an  accident  is  accompanied  by  pain,  vomiting,  rapid  pulse,  and 
other  constitutional  disturbance,  at  times  amounting  to  profound  shock.  Kup- 
ture  of  an  ovarian  cyst  may  also  be  difficult  to  differentiate  from  the  rupture 
of  an  ectopic  gestation-sac;  in  such  cases  the  history  and  the  vaginal  examina- 
tion will  clear  up  the  diagnosis. 

To  summarize  briefly,  it  may  be  said  that  the  diagnosis  of  ectopic  gesta- 
tion depends  upon  the  following  cardinal  points  : 

1.  A  history  of  probable  pregnancy. 

2.  Paroxysmal  pains,  usually  located  on  one  or  the  other  side  of  the  pelvis. 

3.  Irregular  metrostaxis. 

4.  The  expulsion  of  bits  of  decidua. 

5.  Coincident  enlargement  of  the  uterus  and  softening  of  the  cervix  and 

discoloration  of  the  vagina. 

6.  Tumor  lateral  or  posterior  to  uterus  and  indirectly  connected  with  it, 

uterus  moderately  or  not  at  all  enlarged. 

7.  Changes  in  the  breast. 

8.  Anemia. 


THE    PATHOLOGY   OF  PREGNANCY. 


339 


The  diagnosis  of  ectopic  gestation  after  the  death  of  the  fetus  is  largely 
dependent  upon  the  clinical  history;  if  this  be  deficient,  the  diagnosis  is  fre- 
quently impossible,  especially  if  there  has  been  a  long  interval  between  the 
rupture  and  the  time  when  the  patient  consults  the  physician.  If  the  fetus 
has  undergone  calcification,  it  may  be  felt  as  a  hard  mass,  but  even  this  is  not 
conclusive,  as  a  calcified  myoma  may  present  similar  characteristics. 

Treatment. — From  the  operative  standpoint  it  is  best  to  divide  ectopic 
pregnancy  into  the  following  periods : 

1.  Before  rupture;  2,  at  the  time  of  rupture ;  3,  after  rupture;  and  4, 
after  calcification,  saponification,  mummification,  or  suppuration  of  the  fetus 
has  occurred. 

1.  Before  Rupture. — The  electrical  treatment,   so  much  advocated  a  few 


Fig.  162.— Diagram  of  intraperitoneal  rupture  of  tubal  pregnancy.    Free  blood  in  Douglas's  cul-de-sac 
and  among  the  intestines  (Dickinson) :  S,  symphysis ;  R,  rectum. 


years  since  for  the  destruction  of  the  fetus,  while  valuable  in  its  day  as  pio- 
neer work,  has  deservedly  fallen  into  disrepute,  because  of  its  uncertainty  in 
terminating  the  fetal  life  and  of  its  dangers  to  the  mother  through  subsequent 
inflammation.  The  injections  of  fluids  into  the  sac  for  the  same  purpose  is 
so  utterly  foreign  to  present  ideas  of  treatment  that  it  is  only  mentioned  to 
be  condemned.  The  proper  course  to  pursue  is  the  removal  of  the  affected 
tube.  Precipitate  operation,  however,  is  not  advisable,  as  the  diagnosis  should 
be  as  accurate  as  possible  before  resorting  to  radical  measures.  Cases  with  a 
history  suggestive  of  ectopic  gestation  and  a  mass  lateral  to  the  uterus  detected 
by  vaginal  examination  should  be  operated  upon  without  hesitation.  A  cer- 
tain proportion  of  such  cases  will  prove  to  be  pyosalpinx  or  hydrosalpinx, 
but  an  error  is  not  serious,  as  in  either  instance  operation  is  indicated.     The 


340 


AMERICAN    TENT-BOOK    OF    OBSTETRICS. 


utmost  care  must  be  taken  not  to  rupture  the  thin-walled  sac  by  the  pressure 
of  the  hands  during  an  examination. 

2.  At  the  Time  of  Rupture. — If  called  at  the  time  of  rupture,  the  surgeon 
must  operate  immediately.  While  the  surgeon  is  making  his  preparations  the 
patient  should  be  elevated  with  the  hips  high  in  the  bed,  to  throw  the  blood 
as  much  as  possible  into  the  upper  part  of  the  body.  She  should  receive  at 
once  an  infusion  of  a  quart  of  normal  saline  solution  under  the  breasts.  I 
prefer  to  do  this  with  the  two  caunulse  of  Sweetnam,  of  Toronto,  by  which 
both  breasts  are  injected  at  one  time.  Hypodermics  of  strychnin  should  be 
given  every  half  hour,  at  first  -^  and  after  that  ^  of  a  grain.  A  hot  stim- 
ulating rectal  enema  containing  coffee  and  about  30  grains  of  carbonate  of 
ammonia  is  of  value.     I  would  also  in  a  bad  case  firmly  bandage  the  four 

limbs,  so  as  to  keep  what 


little  blood  was  left  in  the 
body.  Hot  bags  or  bottles 
will  also  aid  in  keeping  up 
the  vitality. 

Preparation  for  Opera- 
tion.— The  chances  for  re- 
covery following  operation 
in  extra-uterine  pregnancy 
depend  upon  the  careful 
observation  of  all  the  de- 
tails of  antiseptic  and  asep- 
tic technique.  For  this 
reason  a  precipitate  opera- 
tion is  always  attended  with 
greater  danger,  as  of  necessity  care  in  details  must  be  sacrificed.  The  surgeon 
should  alwavs  have  a  complete  set  of  abdominal  instruments  and  accessories 
sterilized  and  packed  ready  for  use.  If  the  operation  is  hurried,  select  a  well- 
lighted  room  or  provide  a  portable  electric  light ;  remove  all  unnecessary  fur- 
niture, dampen  the  floor  to  prevent  dust  rising,  but  do  not  disturb  the  curtains 
and  other  hangings  further  than  is  absolutely  necessary.  A  common  kitchen 
table  can  be  turned  into  an  operating-table,  with  a  chair  inclined  against  one 
end,  upon  which  the  patient's  feet  may  rest.  Cover  the  table  with  a  folded 
blanket,  lav  upon  this  an  ovariotomy  drainage  cushion,  and  place  a  small 
pillow  at  the  head. 

As  it  may  be  necessary  to  irrigate,  a  douche-bag  should  be  suspended  in 
a  convenient  position  near  to,  and  about  4  feet  above  the  level  of,  the  table. 
Two  smaller  tables  are  required  for  the  instruments  and  dressings,  and  three 
or  four  chairs  for  the  wash-basins  and  sponge-dishes.  A  room  thus  hastily 
improvised  serves  admirably  for  an  operating-room. 

An  abundance  of  boiled  water  is  necessary.  Directions  should  be  given 
immediately  after  deciding  to  operate  concerning  the  preparation  of  the  water. 
A  wash-boiler  or  other  large  tin  vessel   must  be  scalded  thoroughly,  and  be 


Fig.  163.— Dr.  Peck's  ease  (Youngstown,  Ohio)  of  extra-uterine 
pregnancy  in  the  third  month ;  operation  at  time  of  rupture ; 
recovery. 


THE   PATHOLOGY   OF  PREGNANCY.  341 

partially  filled  with  water  which  is  allowed  to  boil  for  an  hour  if  possible. 
It  is  best  to  let  the  water  cool  to  110°  F.,  but  if  time  is  pressing  pure  cold 
water  from  a  well  or  a  hydrant  may  be  used  for  reducing  it  to  proper  tem- 
perature. This  method  of  cooling  the  water,  however,  is  not  advisable  except 
under  stringent  necessity. 

Great  care  must  be  observed  by  the  physician  in  disinfecting  his  hands : 
they  should  be  scrubbed  thoroughly  with  a  nail-brush  with  soap  and  water, 
followed  in  succession  by  immersion  in  permanganate  of  potassium  (hot  sat. 
sol.)  and  oxalic  acid  (hot  sat.  sol.).  A  quart  of  each  of  these  solutions  is 
sufficient.  Or,  better  still,  he  should  scrub  his  hands  rapidly  and  then  put 
on  a  pair  of  sterilized  rubber  gloves.  The  nurse  and  assistants  aiding  him 
should  also  wear  gloves.  The  patient,  under  anesthesia,  is  then  transferred 
to  the  operating-table  and  is  rapidly  prepared  for  abdominal  section.  The 
anterior  and  lateral  surfaces  of  the  abdomen  are  thoroughly  washed  with 
soap  and  water,  followed  by  alcohol,  then  by  ether,  and  finally  by  bichlorid 
solution  (1  :  1000).  As  it  may  be  necessary  to  open  the  sac  through  the 
vagina,  this  passage  should  be  washed  thoroughly  with  soap  and  water,  fol- 
lowed by  bichlorid  solution  (1  :  1000)  and  an  iodoform  pack.  All  dressings, 
towels,  and  gauze  to  be  used  in  immediate  proximity  to  the  field  of  operation 
are  best  provided  by  the  surgeon,  who  should  always  carry  them  among  his 
accessories,  as  the  sterilization  of  these  articles  cannot  be  entrusted  to  an 
untrained  person.  Instruments  are  taken  from  their  sterilized  envelope  and 
placed  on  towels  or  in  trays. 

77ie  Operation. — The  patient  is  put  on  the  table  with  the  pelvis  elevated, 
about  a  foot  above  the  level ;  the  abdomen  is  then  opened  freely  in  the  median 
line;  if  there  has  been  much  hemorrhage,  the  clots  should  be  turned  out, 
exposing  the  ovarian  and  uterine  arteries,  which  ai-e  caught  either  with  for- 
ceps or  between  the  fingers.  If  on  attempting  to  clear  the  pelvis  of  clots 
fresh  blood  wells  up,  no  further  time  should  be  lost  in  attempts  to  expose 
the  bleeding  points,  but  the  operator  must  introduce  his  hand  into  the  pelvis, 
grasp  the  uterine  and  ovarian  arteries,  and  then  apply  hemostatic  forceps, 
guided  by  the  sense  of  touch  alone.  Having  controlled  the  active  hemor- 
rhage, he  must  then  carefully  cleanse  the  abdomen  of  clots,  preserving  the 
debris  as  he  does  so,  in  order  to  discover  the  embryo  or  the  tubal  mole. 

If  the  pregnancy  is  in  the  first  or  second  month,  the  radical  operation 
consists  of  a  simple  salpingo-oophorectomy  of  the  diseased  side.  If  the  ovary 
is  easily  isolated,  the  uterine  tube  alone  should  be  removed.  In  the  case  of  a 
young  woman  in  whom  the  opposite  uterine  tube  was  diseased  or  had  been 
removed,  I  would  be  willing  even  to  empty  the  tube  and  ligate  the  nearest 
large  vessels  and  close  the  abdomen  with  an  iodoform  gauze  drain,  in  the 
hope  that  with  complete  recovery  she  might  still  be  able  to  pass  through  a 
normal  pregnancy.  If,  however,  the  term  is  farther  advanced  and  the  pla- 
centa is  extensively  attached  to  surrounding  structures,  the  uterus,  the  blad- 
der, the  intestines,  and  pelvic  walls,  the  operation  is  not  so  simple,  and  calls  for 
good  judgment  to  determine  howr  best  to  deal  with  the  placenta.    It  is  exceed- 


342  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

i'.igly  hazardous  to  attempt  the  forcible  removal  of  a  placenta  which  is  firmly 
attached,  as  the  hemorrhage  following  its  dislodgement  may  be  so  extensive 
as  to  defy  control.  In  such  cases  it  is  best  to  leave  the  placenta  in  situ,  for 
to  attempt  its  removal  would  take  away  any  chance  the  patient  has  for  life 
in  her  condition  of  shock  and  exsanguiuation. 

In  an  extreme  case  no  means  further  than  those  necessary  to  save  life  at 
the  time  of  operation  should  be  undertaken,  as  the  essential  principle  is  first 
to  control  hemorrhage,  leaving  subsidiary  conditions  for  subsequent  consid- 
eration. If  the  placenta  is  attached  exclusively  to  the  floor  of  the  tube  or 
the  pelvis,  its  blood-supply  may  be  derived  from  numerous  vessels,  and  an 
attempt  to  control  these  by  ligation  would  be  impossible.  The  best  course 
to  pursue  in  such  cases  is  to  check  the  hemorrhage,  tie  and  cut  the  cord  close 
to  its  placental  origin,  and  leave  the  placenta  undisturbed.  Drainage  should 
not  be  employed  in  these  cases,  because  of  the  increased  danger  of  sepsis. 
The  proper  treatment  is  to  close  the  abdomen  completely,  and  after  the 
patient  has  recovered  a  second  operation  may  be  performed  for  the  removal 
of  the  placenta  if  it  causes  untoward  symptoms.  The  greatest  care  in  aseptic 
and  antiseptic  details  should  be  observed,  as  upon  the  absence  of  infection 
depends  the  patient's  chance  for  recovery  when  the  placenta  is  not  removed. 
If  the  operation  is  aseptic,  the  prognosis  is  good,  and  the  placenta  may 
atrophy  and  give  no  further  trouble.  If,  however,  the  wound  is  infected, 
suppuration  of  the  placental  mass  may  occur,  terminating  in  general  peri- 
tonitis or  in  a  pelvic  abscess.  Often  in  the  course  of  an  oj)eration  the  pla- 
centa becomes  detached  and  may  be  removed  with  the  fetus.  In  all  cases  in 
which  the  operation  follows  the  death  of  the  fetus  by  some  days  or  weeks  the 
placenta  is  held  by  only  the  slightest  attachment  or  it  may  lie  free  in  the 
gestation-sac.  It  is  for  this  reason  that  the  operation  is  more  favorable  at 
such  a  time,  as  the  dangers,  of  hemorrhage  are  greatly  decreased. 

In  some  cases,  especially  those  in  which  there  is  a  temporary  cessation  of 
the  bleeding,  the  slightest  disturbance  of  the  sac  after  the  abdominal  cavity 
is  opened  causes  a  renewal  of  the  hemorrhage.  Bold  surgical  measures  are 
then  demanded  :  the  operator  should  sweep  his  hand  rapidly  around  the 
ectopic  sac,  loosening  the  adhesions,  after  which  the  sac  is  delivered  from 
its  bed  of  adhesions.  The  points  of  bleeding  can  then  be  reached  and  con- 
trolled by  forceps. 

In  case  there  is  extensive  oozing  on  the  floor  of  the  pelvis  after  the 
removal  of  the  placenta,  which  it  is  difficult  or  impossible  to  control  by  liga- 
tures, a  strip  of  iodoform  gauze  should  be  packed  firmly  clown  upon  the 
bleeding  points.  When  there  is  much  fluid  and  many  clots  are  scat- 
tered throughout  the  abdominal  cavity,  free  irrigation  with  sterilized  normal 
salt  solution  (6  per  cent.)  at  a  temperature  of  110°  F.  should  be  employed  ; 
3  or  4  liters  (3  or  4  cpiiarts)  of  the  solution  may  be  necessary  to  cleanse  the 
cavity.  There  is  no  danger  from  the  distribution  of  this  material  in  the 
abdomen  by  irrigation,  as  the  ectopic  product  is  usually  sterile. 

In  all  ectopic  cases  that  undergo  operation  the  opposite  tube  and  ovary 


THE   PATHOLOGY   OF  PREGNANCY.  343 

should  closely  be  examined,  and  if  seriously  diseased,  their  extirpation  is 
demanded :  to  allow  a  diseased  tube  and  ovary  to  remain,  which  can  be  of 
little  if  any  further  functional  value,  would  only  subject  the  patient  to  the 
dangers  of  a  subsequent  ectopic  pregnancy  or  to  the  discomfort  and  pain  due 
to  adherent  appendages.  In  most  cases,  however,  the  tube  alone  is  affected 
and  the  ovary  is  only  accidentally  involved  in  the  adhesions. 

3.  Some  Days  or  Weeks  after  Rupture. — Cases  are  not  usually  submitted 
to  operation  at  the  time  of  rupture,  as  by  the  time  the  surgeon  is  called  the 
patient  is  either  recovering  or  is  dead  from  extensive  hemorrhage.  In  a 
certain  proportion  of  cases  the  patient,  although  feeling  the  sharp  pain 
accompanying  the  rupture  and  being  compelled  to  keep  to  her  bed  for  a  day 
or  so  on  account  of  weakness,  does  not  call  her  physician,  as  she  considers  it 
only  a  trifling  matter  associated  with  her  pregnancy.  There  occur  undoubt- 
edly a  considerable  number  of  cases  like  the  latter  in  which  the  death  of 
the  fetus  occurs  at  the  time  of  rupture  and  no  further  symptoms  are  observed, 
and  the  patient  makes  a  perfect  recovery.  It  is  for  this  reason  that  a  statis- 
tical table  compiled  for  the  purpose  of  ascertaining  the  rate  of  mortality  in 
extra-uterine  pregnancies  due  to  rupture  is  fallacious. 

The  life  of  the  fetus  must  not  influence  the  determination  to  operate,  and 
under  no  circumstances  should  operation  be  delayed  on  account  of  sentiment 
in  its  behalf. 

As  the  dangers  of  operation  greatly  increase  as  the  pregnancy  advances 
toward  term,  on  account  of  the  development  of  the  placenta  increasing  the 
dangers  of  hemorrhage,  the  earliest  date  possible  should  be  selected  for  opera- 
tion. A  free  incision  should  be  made  in  the  central  line  of  the  abdomen.  If 
the  pregnancy  is  in  the  early  weeks,  the  operation  may  be  no  more  difficult 
than  a  salpingo-oophorectomy  for  pyosalpinx  or  for  hydrosalpinx.  The  dan- 
ger of  hemorrhage,  however,  from  the  broad  ligament  is  somewhat  greater 
than  in  the  ordinary  salpingo-oophorectomy,  on  account  of  the  increased  vas- 
cularity of  the  tube,  and  great  care  should  be  exercised  in  placing  the  ligatures 
so  that  they  will  control  all  blood-vessels.  The  transfixion  needle  should  not 
be  employed  for  this  purpose,  as  the  subsequent  shrinkage  of  tissue  following 
the  removal  of  the  vascular  tube  is  liable  'to  dislodge  the  ligature,  as  more 
tissue  is  usually  included,  and  a  larger  size  of  silk  is  employed,  than  when  the 
ligament  is  tied  off  in  small  sections.  The  pregnant  tube  when  the  ligatures 
are  laid  should  be  lifted  well  out  of  its  bed  with  a  medium-sized  curved  needle 
armed  with  a  carrier.  The  medium-sized  silk  suture  is  the  best  in  this  loca- 
tion, as  it  stands  sufficient  strain  easily  to  control  hemorrhage,  and  yet  does 
not  strangulate  the  tissues  en  masse.  Each  suture  should  overlap,  in  an  imbri- 
cated manner,  the  one  placed  immediately  before  it ;  thus  no  vessels  can  pos- 
sibly escape  ligation. 

If  pregnancy  is  further  advanced  and  adhesions  have  formed  between  the 
gestation-sac  and  the  adjacent  viscera  or  the  pelvic  floor,  or  if  it  is  a  broad-, 
ligament  gestation  with  the  placenta  firmly  implanted  on  the  pelvic  floor,  the 
operation  becomes  one  of  the  most  difficult  in  abdominal  surgery.     The  adhe- 


344  AMERICAN   TEXT- BO  OK    OF    OBSTETRICS. 

sions  should  be  dissected  off  carefully,  all  bleeding  points  should  promptly  be 
ligated,  and  the  sac  should  be  enucleated  in  the  ordinary  manner.  Drainage 
should  not  be  used  if  it  can  possibly  be  avoided;  only  persistent  oozing  which 
cannot  be  controlled  by  ligatures  justifies  its  employment,  as  the  dangers  of 
infection  are  greatly  increased  by  leaving  the  abdominal  cavity  open. 

The  fact  that  particles  of  clots  and  other  debris  are  scattered  throughout 
the  abdominal  cavity  does  not  render  drainage  necessary,  as  such  material  is 
innocuous  if  the  field  has  been  kept  aseptic,  and  it  will  give  no  trouble  if  the 
wound  is  hermetically  sealed. 

In  densely  adherent  or  broad-ligament  cases  enucleation  of  the  sac  is 
often  impossible,  and  other  measures  must  be  resorted  to  for  the  relief  of 
the  patient.  The  treatment  of  the  ectopic  sac  then  becomes  a  question  of 
great  importance,  as  the  adhesions  to  neighboring  viscera  or  to-  the  pelvic 
floor  may  be  so  extensive  as  to  preclude  its  removal,  as  the  danger  of  hem- 
orrhage following  its  enucleation  is  too  great  in  such  cases.  This  question 
should  usually  be  decided  after  the  abdomen  is  opened.  The  extent  of  adhe- 
sions and  the  vascularity  of  the  sac  and  adjacent  tissue  should  be  noted  care- 
fully, and  if  of  such  a  degree  as  to  contraindicate  removal,  the  next  measure, 
that  of  making  an  extraperitoneal  opening,  must  be  resorted  to. 

Treatment  by  Vaginal  Opening  and  Drainage. — In  early  extra-uterine 
pregnancies,  in  which  a  rupture  has  occurred  several  weeks  or  more  before 
the  surgeon  has  seen  the  case,  a  valuable  method  of  treatment,  applicable  to 
a  large  percentage  of  cases,  is  the  making  of  a  free  vaginal  opening  into  the 
sac,  the  evacuation  of  the  sac,  and  free  drainage  with  iodoform  gauze.  This 
method  of  treatment  is  suitable  only  where  a  bimanual  examination  reveals 
a  well-defined  mass  low  down  in  the  pelvis,  easily  reached  through  the 
vagina,  in  a  case  in  which  the  history  shows  that  the  rupture  has  occurred 
several  weeks  previously.         t 

While  this  method  of  treatment  may  be  adopted  with  some  hesitation  in 
the  cases  just  described,  it  is  pre-eminently  the  best  way  to  handle  those 
extra-uterine  pregnancies  in  which  there  are  elevation  of  temperature  and 
much  local  tenderness  and  evidence  of  incipient  suppuration  of  the  sac. 
In  these  latter  cases  the  vaginal'  route  is  often  far  less  dangerous,  when  the 
patient  is  emaciated  and  very  ill,  and  entails  none  of  the  dangers,  while 
obviating  most  of  the  risks,  of  the  abdominal  route,  and  at  the  same  time 
yielding  a  perfectly  satisfactory  result  in  the  final  outcome. 

When  such  a  method  of  treatment  is  adopted,  the  operator  should  hold 
himself  in  readiness  to  open  up  the  abdomen  at  once  and  to  expose  and 
control  the  cardinal  vessels  in  the  event  of  such  an  accident  as  an  excessive 
hemorrhage.  I  have  had  to  do  this  twice  before  the  patient  left  the  operat- 
ing-room, and  both  patients  recovered.  One  of  my  colleagues  lost  a  life  from 
hemorrhage  following  an  attempted  vaginal  evacuation. 

The  method  of  performing  the  operation  is  as  follows :  The  anatomical 
relations  of  the  sac  are  carefully  studied  first ;  then,  with  the  middle  finger 
in  the  rectum  and  the  index-finger  in  the  vagina,  resting  on  the  prominent 


THE  PATHOLOGY   OF  PREGNANCY.  345 

portion  of  the  sac  behind  the  cervix,  the  operator  thrusts  a  pair  of  sharp- 
pointed  scissors  through  the  posterior  fornix  of  the  vagina  into  the  sac, 
taking  care  to  follow  the  axis  of  the  pelvis,  and  not  to  transfix  the  bowel 
with  the  point  of  the  scissors.  The  moment  the  sac  is  opened  there  is  an 
escape  of  blood.  The  operator  then  takes  the  largest  sized  dilator  and 
stretches  the  wound  as  widely  as  possible  until  it  is  big  enough  to  admit 
three  fingers.  The  cavity  is  then  emptied  of  all  its  blood,  and  the  laminated 
clots  are  drawn  out  by  the  fingers  until  the  pelvis  is  ft-eed  of  its  burden.  The 
irrigation  must  not  be  used  unless  it  is  perfectly  evident  that  there  is  no  com- 
munication with  the  abdominal  cavity  above.  If  the  sac  has  been  a  suppu- 
rating one,  the  cavity  would  next  be  best  washed  out  with  a  formalin  solution 
(1  :  500).  The  next  step  is  to  fill  the  cavity  loosely  with  a  washed-out 
iodoform  gauze  drain.  The  drain  may  be  left  in  for  six  or  seven  days  or 
longer,  so  long  as  the  discharge  l'emains  pure  and  sweet  and  there  is  no 
evidence  of  any  pent-up  suppuration.  With  the  gradual  withdrawal  of  the 
drain  the  sac  collapses,  and  finally  it  closes  completely. 

Evacuation  of  an  Extraperitoneal  Gestation-sac. — The  point  of  opening 
depends  entirely  upon  the  location  of  the  sac :  if  it  is  situated  low  in  the 
pelvis  and  is  of  easy  access  through  the  vagina,  unquestionably  the  best 
method  of  procedure  is  to  evacuate  the  contents  of  the  sac  into  that  canal  and 
establish  free  drainage.  The  best  method  of  opening  the  sac  is  as  follows : 
After  carefully  examining  the  pelvic  mass  and  deciding  where  the  accessible 
point  for  opening  is — usually  in  the  fornix — the  operator  thrusts  a  pair  of 
medium-sized  sharp  scissors,  guided  by  the  index  finger  of  the  vaginal  hand, 
into  the  sac,  and  withdraws  them  partially  open ;  this  is  followed  by  larger 
scissors,  which  are  also  withdrawn  in  the  same  manner.  AYhile  doing  this  it 
is  usually  best  for  the  operator  to  have  his  assistant  press  the  sac  gently  down- 
ward through  the  abdominal  incision.  After  evacuating  the  embryonic  debris 
with  the  fingers  or  with  placental  forceps,  the  sac  should  be  irrigated  freely 
with  sterilized  water  or  with  a  very  weak  bichlorid  solution  (1  :  20,000),  fol- 
lowed by  warm  water.  After  cleansing  the  sac  thoroughly  it  can  be  packed 
with  iodoform  gauze,  care  being  taken  to  leave  a  free  opening  for  subse- 
quent discharge. 

The  greatest  care  must  be  observed  in  passing  from  the  abdominal  to  the 
vaginal  operation,  as  to  make  a  vaginal  examination  followed  by  the  manip- 
ulation necessary  to  evacuate  the  sac  by  the  vagina,  and  then  to  close  the 
abdomen  without  the  most  careful  disinfection  of  the  hands,  would  be  an 
unpardonable  mistake.  It  is  usually  best  for  the  operator  to  entrust  the 
closure  of  the  abdomen  to  his  assistant.  If  the  sac,  instead  of  being  in  close 
relation  with  the  vaginal  fornix,  is  found  to  be  pushed  up  above  the  uterus, 
and  is  situated  nearer  the  anterior  abdominal  wall,  the  vaginal  method  of 
treatment  is  not  advisable,  as  there  may  be  an  intervening  space  communi- 
cating with  the  general  peritoneal  cavity  between  the  ectopic  sac  and  the  vagi- 
nal fornix,  making  it  both  difficult  and  dangerous  to  reach  the  sac.  In  these 
cases  it  may  be  necessary  to  stitch  the  sac  to  the  abdominal  wound,  and  then 


346  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

to  make  an  extraperitoneal  opening  into  it.  As  a  rule,  however,  the  sac  will 
be  attached  by  close  adhesions  to  the  abdominal  wall  above  Poupart's  liga- 
ment, and  should  be  opened  in  this  region.  The  sac  should  be  washed  out 
freely  as  in  the  vaginal  method,  and  be  packed  with  gauze. 

The  after-treatment  in  these  cases  is  often  of  great  importance,  as  the  sac 
fills  up  very  slowly  and  there  is  constant  purulent  discharge.  The  opening 
must  not  be  allowed  to  close.  As  a  rule,  the  gauze  which  is  inserted  at  the 
time  of  operation  should  be  withdrawn  one  piece  at  a  time.  After  the 
removal  of  the  last  piece,  usually  about  the  second  or  third  day,  fresh  gauze 
should  be  inserted,  the  cavity  being  first  freely  irrigated  with  some  mild  fluid, 
such  as  boracic-acid  solution  (semi-saturated). 

4.  Operation  after  the  Fetus  has  undergone  Mummification,  Calcification, 
Saponification,  or  Suppuration. — The  fetus  may  remain  for  years  in  any  one 
of  these  conditions,  except  that  of  suppuration,  without  injury  to  the  mother's 
health.  Soon  after  the  death  of  an  ectopic  fetus  the  liquor  amnii  is  absorbed, 
the  placental  circulation  ceases,  and  the  vascular  connection  between  the  fetus 
and  the  mother  is  broken.  The  liquid  portion  of  the  ectopic  product  is  grad- 
ually absorbed,  leaving  in  many  instances  the  fetus  isolated  in  its  sac  as  an  in- 
nocuous body.  In  such  cases  operation  should  not  be  performed  so  long  as  the 
patient's  health  remains  good,  but  on  the  first  indication  of  constitutional  dis- 
turbance, especially  if  febrile  in  character,  celiotomy  for  the  removal  of  the 
foreign  body  should  promptly  be  resorted  to.  If  suppuration  occurs  and  the 
pus-sac  opens  into  the  rectum,  the  vagina,  the  bladder,  or  externally  through 
the  abdominal  wall,  the  fistula  should  be  enlarged  and  the  fetal  debris  be 
removed.  The  sac  should  then  be  irrigated  frequently  until  it  fills  with  gran- 
ulation tissue.     These  sinuses  heal  with  difficulty,  and  they  may  be  persistent. 

8.  Diseases  of  the  Fetus. 

Of  the  many  diseases  that  may  attack  the  fetus  in  utero,  some  cause  its 
death  and  expulsion,  others  influence  its  growth  and  development  in  varying 
degrees,  while  others  run  their  course  during  intra-uterine  existence  and  end 
in  recovery.  A  mortality  of  20  per  cent,  is  a  low  estimate  of  the  death-rate 
of  intra-uterine  existence.  Hereditary  influences,  particularly  noticeable 
when  either  or  both  parents  are  subjects  of  disease  of  the  nervous  s}'stem  or 
of  chronic  disorders  of  nutrition,  furnish  a  large  number  of  fetal  deaths; 
such  affections  are  epilepsy,  chorea,  inebriety,  diabetes,  cancer,  nephritis, 
phthisis,  and,  especially,  syphilis.  Certain  infectious  diseases  are  directly 
transmitted  to  the  fetus  ;  continued  high  elevation  of  temperature  in  the 
mother,  blood  surcharged  with  vai-ious  poisons,  alterations  in  the  maternal 
blood  pressure,  diseases  of  the  uterus  or  its  appendages ;  mechanical  disturb- 
ances or  injuries,  are  important  causes  of  fetal  morbidity  and  mortality. 

Heredity. — It  is  as  difficult  to  explain  satisfactorily  and  scientifically 
heredity  as  it  is  to  solve  the  mystery  of  life  itself.  The  unmistakable  evi- 
dences of  heredity  in  physical  resemblance,  in  mental  and  even  moral  char- 
acteristics,  as    shown    frequently   between    parent    and    offspring,    are    best 


THE   PATHOLOGY    OF   PREGNANCY.  :>A1 

explained  by  the  mechanical  theory  generally  accepted  by  physiologists. 
Fertilization  means  the  union  of  a  definite  quantity  of  nuclein  or  chromatin 
of  the  spermatic  particle  with  a  similar  quantity  of  the  same  substance  in  the 
ovule.  From  the  moment  those  substances  unite,  endowed  as  they  are  with 
potential  vital  characteristics  of  the  individuals  whence  they  originated,  we 
can  as  readily  believe  that  potentiality  for  disease  will  characterize  the  prod- 
uct of  conception  as  we  can  and  do  believe,  what  we  often  see,  the  inheri- 
tance of  physical,  mental,  and  moral  attributes. 

The  actual  and  ultimate  pathologic  changes  thus  occurring  in  the  morpho- 
logic elements  that  unite  to  produce  a  new  entity,  we  certainly  do  not,  and, 
perhaps,  never  can  know.  We  must  certainly  accept  as  reasonable  hereditary 
influences  which  lower  vitality,  predispose  to,  or  actually  produce,  disease 
during  and  after  intra-uterine  life. 

Inebriety. — Nicloux*  asserts  that  in  intemperate  women  enough  alcohol 
reaches  the  fetal  circulation  to  produce  a  chronic  intoxication  or  congenital 
alcoholism,  which  expresses  itself  in  various  nervous  derangements.  The 
investigations  of  Sullivan, f  who  carefully  studied  the  history  of  the  offspring 
of  chronic  drunkards,  show  that  the  death-rate  of  the  infants  of  inebriate 
mothers  was  nearly  two  and  a  half  times  that  of  the  infants  of  sober  women 
of  the  same  stock.  A  decrease  of  vitality  in  the  successive  children  of  the 
alcoholic  family  was  also  noted.  Thus,  in  one  family  the  three  first-born 
children  were  healthy,  the  fourth  exhibited  defective  intelligence,  the  fifth 
was  an  epileptic  idiot,  the  sixth  was  dead  born,  and  the  seventh  pregnancy 
ended  in  abortion.  Sober  paternit)r  had  little  influence  when  maternal  in- 
ebriety was  present,  and  might  almost  be  neglected  in  an  estimate  of  the 
vitality  of  the  offspring.  Conception  during  drunkenness  had  a  distinct 
influence,  as  was  shown  by  the  fact  that  of  the  7  cases  in  which  the  condition 
was  noted,  in  6  the  children  died  in  convulsions  in  the  first  month  of  life, 
and  in  the  seventh  case  the  child  was  still-born.  Of  the  children  of  drunken 
mothers  that  survived  their  infancy,  4.1  per  cent,  were  epileptics.  The 
records  of  the  hospitals  for  the  insane,  the  histories  of  epileptics,  of  crimi- 
nals, and  of  degenerates  show  conclusively  the  frightful  heritage  of  inebriety. 
Statistics  of  fetal  death  from  this  cause  alone  are  practically  impossible  to 
obtain,  because  other  diseases  are  so  frequently  associated  with  inebriety, 
whose  baneful  influence  on  fetal  growth  and  development  is  well  known. 

Infections  of  the  Fetus. — Syphilis. — Syphilitic  infection  of  the  fetus 
is  the  most  important,  because  the  most  common  and  serious,  disease  that 
affects  the  product  of  conception.  Habitual  premature  expulsion  of  the  fetus 
is  almost  always  due  to  syphilis.  Abortion,  premature  labor,  still-births  at 
term,  and  death  during  the  early  months  of  infantile  life  can  very  frequently 
be  traced  to  syphilitic  infection,  the  period  at  which  death  occurs  being 
dependent  upon  the  time  when  infection  of  the  product  of  conception  has 
occurred  and  upon  the  virulence  of  the  infection.  The  infection  may  be 
from  the  father,  the  spermatic  particle  endowing  the  ovum  with  all  the  pos- 
*  L' Obstetrique,  March  15,  1900.  t  Am.  Year-Book  Med.  and  Surg.,  1901. 


348  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

sible  pathologic  changes  induced  by  syphilis.  The  mother  of  a  syphilitic 
product  of  conception,  being  originally  free  from  syphilitic  infection,  may  or 
may  not  exhibit  the  evidences  of  syphilis.  Most  syphilographers  agree  that 
such  a  mother  acquires  either  the  disease  or  an  apparent  immunity  against  it. 
Thus  are  explained  the  occurrence  of  secondary  symptoms  in  a  pregnant 
woman  who  has  never  had  a  primary  sore  and  Codes'  law,  that  a  nursing 
mother  never  acquires  syphilis  from  her  own  syphilitic  child.  When  the 
mother  is  syphilitic  at  the  time  of  conception,  the  ovum  is  diseased,  and  prema- 
ture expulsion  of  the  fetus  is  the  rule.  Should  the  mother  acquire  syphilis 
after  conception,  the  clangers  to  the  ovum  from  infection  are  greater  the  ear- 
lier in  the  pregnancy  the  infection  occurs.  When  one  or  both  parents  are, 
or  have  been,  syphilitic,  there  is  no  time  limit  after  which  the  danger  of 
fetal  infection  has  passed,  although  it  is  rare  for  syphilis  to  appear  in  the 
infant  when  the  infected  parent  has  shown  no  signs  of  the  disease  for  a 
period  of  four  years  (Founder). 

Diagnosis. — -There  are  no  signs  by  which  fetal  syphilis  can  be  determined 
until  the  expulsion  of  the  ovum.  The  history  of  recently  acquired  syphilis 
in  either  parent  would  indicate  the  immediate  administration  of  antisyphilitic 
remedies.  In  those  cases  where  the  fetus  has  escaped  death  and  is  born  at 
term  it  may  be  apparently  healthy,  and  the  signs  of  congenital  syphilis  do 
not  appear  until  several  weeks  or  months  have  elapsed. 

Diagnosis  of  Congenital  Syphilis  in  the  Living  Infant. — The  syphilitic 
infant,  frequently  prematurely  born,  is  wasted,  wrinkled,  and  has  the  charac- 
teristic "  old-man  "  or  wizened  appearance.  The  abdomen  is  much  enlarged, 
and  through  the  overstretched  abdominal  wall  the  enlarged  liver  and  spleen 
are  readily  palpable.  An  associated  ascites  is  frequently  present.  Snuffles 
due  to  a  persistent  coryza  is  one  of  the  earliest  symptoms.  The  discharges 
from  the  nose  are  acrid,  often  causing  excoriations  and  fissures  of  the  lips. 
Ulceration  of  the  nasal  bones  may  occur.  The  mucous  membranes  of  the 
larynx  may  be  seriously  inflamed,  or  even  ulcerated,  and  produce  a  character- 
istic hoarseness.  The  earliest,  skin  affection  is  a  roseola,  especially  marked, 
as  are  other  syphilitic  eruptions,  upon  tin-  palms  and  soles.  Erythematous 
patches,  maculopapular,  pemphigoid,  vesicular,  and  pustular  eruptions  soon 
follow.  Condylomata  about  the  anus,  the  vulva,  the  groin,  and  in  other 
folds  of  the  skin  may  be  present.  Enlargement  of  the  liver,  of  the  spleen, 
and  of  the  thymus  gland  are  readily  discovered.  Often  there  is  a  marked 
tendency  to  hemorrhages  from  the  mucous  membranes.  Tenderness  and 
swelling  of  the  long  bones  due  to  osteitis  or  osteochondritis,  cyanosis,  and 
ascites  resulting  from  syphilitic  changes  in  the  liver  are  manifested  as  the 
disease  exhibits  its  characteristic  signs  and  symptoms. 

Diagnosis  of  Congenital  Syphilis  after  Death  of  the  Infant. — The  pathologic 
changes  are  similar  to  those  in  the  adult,  all  the  tissues  of  the  body  being 
involved.  The  most  characteristic  change  is  a  cellular  infiltration  with 
hyperplasia  of  the  connective,  tissue  in  all  the  organs  and  in  any  portion  of 
the  body.     The  organs  which  furnish  the  best  evidence  for  diagnosis  are  the 


THE   PATHOLOGY    OF  PREGNANCY.  349 

long  bones,  the  lungs,  the  liver,  spleen,  and  thymus.  Upon  making  section 
of  the  long  bones  at  the  junction  of  the  diaphysis  and  epiphysis,  instead  of 
finding  a  normally  clear,  narrow,  and  sharp  line  of  demarcation  between 
cartilage  and  bone,  Weger  *  has  demonstrated  a  broad,  yellow,  jagged  line 
in  syphilitic  infants,  shown  by  the  microscope  to  be  a  premature  attempt  at 
ossification  which  has  ended  in  fatty  degeneration,  necrosis,  and  suppuration. 
Other  observers  have  carefully  studied  this  sign,  and  it  is  believed  to  be 
pathognomonic  of  syphilis. 

The  evidences  of  syphilis  to  be  found  in  the  lungs  are,  in  the  order  of 
their  frequency  :  (a)  interstitial  or  fibroid  pneumonia  ;  [b)  gummata ;  and 
(c)  white  hepatization  or  white  pneumonia,  a  peculiar  catarrhal  inflammation. 
In  the  fibroid  pneumonia  the  alveoli  and  blood-vessels  are  seen  to  be 
compressed  by  a  dense  overgrowth  of  connective  tissue.  The  air-spaces  are 
thus  encroached  upon,  but  not  wholly  obliterated  ;  the  lung  substance  is  dark 
red.  When  some  air  has  entered  the  lung  during  imperfect  respiration,  a  cut- 
off portion  will  be  partly  submerged  when  placed  in  water,  but  will  not  sink. 
When  gummata  are  on  the  pleura  or  scattered  through  the  lung  substance, 
they  will  be  recognized  as  yellow  indurations.  The  white  pneumonia 
produces  marked  enlargement  of  the  lungs,  showing  the  imprint  of  the  ribs 
and  a  yellow-white  color  due  to  wide-spread  fatty  degeneration.  The  alveoli 
are  filled  with  fatty  epithelial  cells,  showing  that  air  could  not  enter  the  lungs 
and  that  the  function  of  respiration  had  never  been  established. 

The  enlargement  of  the  liver  in  syphilitic  infants  is  also  due  to  excessive 
growth  of  connective  tissue.  Gummata  are  also  frequently  found  scattered 
throughout  the  organ.  The  liver  of  a  healthy  infant  should  constitute  about 
one-thirtieth  part  of  the  body  weight;  in  a  syphilitic  infant,  Ruge|  has 
shown  that  this  proportion  is  exceeded,  in  some  cases  amounting  to  one-eighth 
of  the  infant's  weight.  A  similar  excess  in  the  weight  of  the  spleen  is  also 
observed,  and  the  thymus  gland  is  much  enlarged. 

Treatment. — The  treatment  of  fetal  syphilis  consists  in  thorough  antisvph- 
ilitic  treatment  of  the  pai-ents.  Should  the  prospective  father  be  known  to 
be  syphilitic,  he  should  be  subjected  to  vigorous  treatment  before  and  after 
marriage,  and  in  the  event  of  his  wife's  conception,  whether  she  be  svphilitic 
or  not,  she  also  should  receive  treatment  throughout  the  pregnancv.  Should 
the  woman  be  a  syphilitic,  treatment  before  and  throughout  pregnancv  is 
required.  Mercury  and  iodid  of  potassium  should  be  given,  and  when  it  is 
desired  to  administer  them  to  the  woman  without  her  knowledge,  they  may 
be  given  in  a  laxative,  such  as  cascara  sagrada.  From  a  study  of  32  cases 
Etienne  found  that  in  cases  where  the  mother  received  no  treatment  the  fetal 
mortality  was  95.5  per  cent.  Every  obstetrician  of  experience  has  observed 
very  different  results  when  the  mother  has  been  subjected  to  careful  treatment 
before  and  during  pregnancy,  the  child  in  such  instances  being  born  healthv 
and  not  showing  throughout  its  life  any  traces  of  syphilis. 

Typhoid  Fever. — In  typhoid  fever  the  effect  of  the  disease  upon  the  fetus 
*  Virchorts  Archiv,  Bd.  i.,  S.  305.  fZeits.f.  Geburtsh.,  Bd.  i. 


350  AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 

is  especially  fatal.  The  percentage  of  cases  in  which  premature  expulsion 
takes  place  varies  from  65  to  75  per  cent,  according  to  different  authors. 
The  causes  of  the  premature  expulsion  are  supposed  to  be  clue  to  the  high 
temperature,  changes  in  the  blood,  and  insufficient  oxygenation  of  the  blood 
as  it  passes  through  the  lungs.  Cases  are  recorded  in  which  the  bacilli  of 
typhoid  fever  have  been  found  in  the  internal  organs — i.  e.,  lungs,  kidneys, 
and  spleen  of  the  fetus  after  premature  expulsion. 

Septicemia. — Intra-uterine  septic  infection  has  been  denied  by  many,  but 
we  have  sufficient  evidence  *  in  recorded  cases  to  confirm  its  occurrence. 
Pus-organisms  have  been  found  in  the  fetus  of  a  mother  suffering  with  septic 
infection,  and  well-formed  collections  of  pus  have  been  found  in  the  fetus  at 
birth.     It  is  rare,  but  undoubtedly  does  occur. 

Malaria. — There  seems  to  be  no  longer  any  doubt  of  the  intra-uterine 
transmission  of  malaria.  Children  have  been  born  with  the  pathologic 
changes  produced  by  malaria —  i.  e.,  enlarged  spleen  and  pigment  granules  in 
the  blood  and  tissues.  Playfair  says  that  the  disturbance  caused  by  the  chill 
is  felt  by  the  mother  as  her  child  in  ufero  passes  through  this  particular  stage 
of  the  disease.  Numerous  cases  are  recorded  in  which  malaria  has  manifested 
itself  directly  after  birth.  Malaria  rarely  terminates  pregnancy,  though  this 
has  taken  place.  Its  presence  in  the  mother,  however,  lias  an  injurious 
influence  on  the  growth  and  development  of  the  fetus.  The  administration 
of  quinin  in  as  large  doses  as  necessary  is  indicated.  No  fear  need  be  appre- 
hended of  causing  an  abortion  or  premature  labor  through  its  administration. 

Variola. — That  variola  occurs  in  intra-uterine  life  is  beyond  dispute. 
The  susceptibility  of  the  fetus,  however,  varies  greatly  ;  in  the  majority  of 
cases  the  fetus  is  not  affected.  The  manifestations  in  the  fetus  are  not  always 
synchronous  with  those  occurring  in  the  mother,  and  are  not  always  similar 
in  character.  A  case  is  recorded  of  a  mother  who  had  been  exposed  to  small- 
pox ;  she  had  no  signs  of  the  disease,  and  was  apparently  in  good  health,  and 
wave  birth  to  a  child  with  pustules  on  it.  Again,  a  mother  who  had  only 
had  varioloid  gave  birth  to  a  child  with  the  scars  of  small-pox  on  it.  In  rare 
instances  vaccination  of  the  mother  has  protected  the  fetus.  Abortion  takes 
place  in  about  50  per  cent,  of  the  cases  of  pregnancy  complicated  by  variola. 
In  the  severer  and  hemorrhagic  forms  it  is  almost  inevitable. 

Measles. — The  transmission  of  measles  from  mother  to  fetus  is  rare,  but 
several  well-authenticated  cases  are  recorded  in  which  children  were  born  in 
the  different  stages  of  the  disease.  In  those  instances  in  which  it  occurred  in 
children  a  few  hours  or  days  after  birth  it  would  appear  from  the  length  of  , 
the  period  of  incubation  that  the  infection  took  place  in  utero.  The  prog- 
nosis is  grave,  both  as  regards  the  mother  and  fetus,  and  especially  if  the 
maternal  infection  takes  place  at  or  near  the  time  of  labor. 

Scarlet  Fever. — The  occurrence  of  scarlet  fever  in  intra-uterine  life  is  rare, 
but  several  well-authenticated  cases  are  on  record  in  which  the  children  were 
born   with  the  eruption  upon  them.     Should  the   mother   become   infected 

*  Centralblalt  f.  Gyn.,  1S85,  p.  200. 


THE   PATHOLOGY    OF  PREGNANCY.  351 

during  pregnancy  the  fetus  is  usually  infected  also,  but  this  is  not  invariably 
the  ride.  The  prognosis  is  grave  for  botli  mother  and  fetus,  esjjecially  if  the 
maternal  infection  takes  place  near  the  end  of  pregnancy. 

Erysipelas. — Lebedeff  *  has  presented  conclusive  evidence  of  the  trans- 
mission of  erysipelas  from  mother  to  fetus.  In  his  case  the  coccus  was  found 
in  the  subcutaneous  tissues  of  the  child.  Cultures  were  made,  and  rabbits 
which  were  inoculated  with  them  contracted  the  disease.  No  cocci  were 
found  in  the  placenta  or  cord.  Erysipelas  is  likely  to  interrupt  pregnancy. 
The  mother  infected  in  the  puerperal  state  may  transmit  it  to  her  new-born 
child.     The  gravity  of  the  prognosis  is  increased  by  the  pregnancy. 

Tuberculosis. — Tuberculosis  may  be  di recti}'  transmitted  from  mother  to 
fetus,  but  it  is  an  extremely  rare  occurrence,  as  the  fetus  is  very  persistent  in 
its  resistance  to  infection  by  the  bacillus.  The  possibility  of  its  transmission 
in  this  manner  has  been  the  subject  of  thorough  investigation.  Ballinger, 
Davaine,  and  Wolff  have  expressed  their  disbelief  in  intra-uterine  trans- 
mission, while  Keating,  Jacobi,  and  others  have  presented  cases  in  which 
there  was  undoubtedly  transmission  from  the  human  mother  to  the  fetus  in 
utero.  Johne  discovered  tubercle  bacilli  in  a  still-born  calf,  and  the  placenta 
has  also  been  found  to  contain  the  bacilli  of  tuberculosis.  The  children  born 
of  a  mother  suffering  from  tuberculosis  are  weak,  puny,  and  predisposed  to 
pulmonary  disease. 

Cholera. — It  is  very  doubtful  whether  cholera  can  be  transmitted  to  the 
fetus  in  utero.  Abortion  nearly  always  takes  place,  due  to  asphyxiation  from 
changes  in  the  maternal  blood.  Should  the  child  be  born  alive,  it  usually 
survives  but  a  few  days. 

Recurrent  Fever. — Cases  of  congenital  recurrent  fever  are  recorded. 
Albrecht  f  reported  a  case  in  which  he  found  the  spirilla  of  recurrent  fever. 
The  fetus  usually  dies,  and  the  pathologic  changes  characteristic  of  this 
disease  are  found — i.  <?.,  enlarged  spleen,  pigment  in  the  spleen  and  in  the 
portal  blood. 

Yellow  Fever. — Dr.  Bemis,  of  New  Orleans,  reports  that  the  offspring 
of  a  woman  who  recovers  from  an  attack  of  yellow  fever  acquired  during  her 
pregnancy  is  immune  to  the  disease. 

Congenital  Deformities  and  Malformations. — Amniotic  Bands. 
— Amniotic  hands  are  due  to  an  insufficient  secretion  of  amniotic  fluid  or 
to  a  plastic  inflammation  of  the  amnion  with  the  exudation  of  a  soft,  but- 
tery material  which,  on  organizing,  forms  adhesions,  which  are  known 
according  to  their  insertion  as  feto-amniotic,  fetal,  and  amniotic.  This 
exudate  is  similar  in  character  to  that  thrown  out  in  the  inflammations  of 
serous  membranes  in  general.  Amniotic  bands  may — (1)  Prevent  the  clos- 
ing over  of  the  head  and  body  cavities,  thus  producing  anencephalus  and 
eventration.  (2)  They  may  cause  premature  separation  of  the  placenta 
during  uterine  contractions  in  labor,  resulting  in  serious  maternal  hemorrhage 
or  death  of  the  child.  (3)  They  may  cause  strangulation  and  intra-uterine 
*Zeit.f.  GeburL,  xii.,  No.  2.  f  St.  Petersburg  med.  Wock,  1S84,  p.  129. 


352  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

amputations — a  limb  may  be  caught  under  one  of  these  dense  bands  and  the 
circulation  partially  or  completely  shut  off.  In  those  cases  where  it  is  only 
partially  shut  off  the  growth  of  the  part  beyond  the  constriction  is  greatly 
arrested  and  undergoes  an  atrophic  process.  A  complete  intra-uterine  ampu- 
tation generally  takes  place  early  in  fetal  life.  When  it  takes  place  prior  to 
the  third  month  the  amputated  member  will  probably  be  fully  absorbed. 
When  it  occurs  later  the  member  will  likely  be  expelled  at  birth. 

Intra-uterine  Fractures. — Intra-uterine  fractures  are  generally  caused 
by  external  violence.  Cases  are  recorded  of  children  being  born  with  one  or 
more  fractures  of  the  bones  and  no  history  of  an  injury  during  pregnancy. 
These  are  probably  due  to  abnormal 
muscular  contractions  in  the  fetus,  a 
diseased  condition  of  the  bones,  or 
both.  The  abnormal  bone  condition 
may  be  due  to  rickets  and  the  frac- 
tures then  are  likely  to  be  multiple  ; 
or  to  a  fetal  bone  disease  described 
by  Link  and  Schmidt.  A  syphilitic 
osteochondritis  may  result  iu  a  sepa- 
ration of  the  epiphysis  and  diaphysis 
of  the  long  bones  simulating  fracture. 
The  conditions  of  intra-uterine  life 
are  not  favorable  to  good  union  of  a 


&*. 


Fig.  164.— Ectromelus  (intra-uterine  amputation).  Fig.  165.— Fetal  rachitis. 

fracture.  If  union  does  take  place,  it  is  usually  with  a  bad  deformity,  which 
may  result  in  a  difficult  labor.  In  fetuses  affected  with  rickets  the  chances 
for  a  good  union  are  especially  unfavorable. 

Congenital  Luxations. — Of  the  various  joints  thus  affected,  the  hip-joint 
is  the  one  by  far  the  most  frequently  involved.  In  Langenbeck's  cases  there 
were  90  luxations  of  the  hip-joint  to  5  of  the  humerus,  2  of  the  radius,  and 
1  of  the  knee.  They  are  more  common  on  one  side,  and  are  often  associated 
with  other  malformations.  They  are  more  frequent  in  females,  87.6  per  cent, 
occurring  in  this  sex.    As  to  the  etiology,  there  are  several  theories  advanced  : 

(1)  That  it  is  due  to  traumatism,  occurring  either  before  birth  or  at  delivery. 

(2)  That  it  is  due  to  a  relaxed  condition  of  the  ligaments  about  the  joint  or  a 
hydrops  of  the  joint.     (3)  That  it  is  due  to  spasmodic  muscular  contractions 


THE   PATHOLOGY    OF   PREGNANCY.  353 

in  the  fetus.  The  theory  which  has  been  accepted  by  must  writers  as  most 
plausible  is  that  it  is  due  to  a  malformation  of  the  acetabulum,  characterized 
by  an  incomplete  formation  of  the  socket  in  which  the  head  of  the  femur 
rests.  The  deformity  is  not  usually  noticed  until  the  child  attempts  to  walk. 
If  it  is  impossible  to  correct  it,  obliquity  of  the  pelvis  and  a  compensatory 
lateral  spinal  curvature  generally  follow. 

Congenital  Tumors. — Congenital  tumors  may  be — (1)  Malignant ;  (2) 
cystic;  (3)  myxomatous;  (4)  tumors  with  fetal  remains;  (5)  sacral  teratoma  ; 
(6)  attached  fetal  members. 

Malignant  tumors  do  not  often  occur,  but  are  occasionally  noted.  They 
may  involve  any  of  the  organs,  but  are  most  likely  to  occur  in  the  liver, 
kidneys,  and  spleen. 

Cystic  tumors  are,  in  most  instances,  hydroeneephalocele  and  spina  bifida  ; 
they  occur  chiefly  in  the  cervical  and  lumbar  regions. 

Myxomatous  tumors  and  tumors  icith  fetal  remains  are  occasionally  found. 
The  latter  result  from  a  cleft  in  the  medullary  fold,  which  gives  origin  to  a 
double  formation,  and  the  production  of  a  tumor  inclosing  fetal  structures. 
These  structures  may  be  rudimentary  limbs,  cartilage,  or  loops  of  intestine. 

Sacral  teratoma  may  be  attached  to  the  sacrum,  the  coccyx,  or  to  both. 
More  frequently  they  are  attached  to  the  coccyx.  They  are  said  to  occur 
more  frequently  in  the  female.  In  a  series  of  58  cases  of  sacral  tumors, 
Molk  found  44  in  females  and  14  in  males. 

Attached  feted  members  are  usually  found  in  the  sacral  or  perineal  regions. 
The  attachment  consists  in  a  limb  or  limbs,  or  a  member  the  result  of  a 
fusion  of  two.     A  pelvic  deformity  usually  accompanies  this  form. 

The  fetus  at  birth  sometimes  presents  an  abdominal  enlargement.  This  may 
be  due  to  an  ascites,  which  is  usually  of  syphilitic  origin,  or  to  a  greatly  overdis- 
tended  bladder.  Malignant  disease  of  the  viscera,  hydronephrosis,ureteral  dilata- 
tion, and  ovarian  tumors  are  some  of  the  other  causes  of  abdominal  enlargement. 

Deformities  op  Special  Regions  and  Organs  of  the  Body. — 
Face. — Harelip,  cleft  palate,  and  fissure  of  the  nose  are  the  deformities  most 
commonly  found  in  the  face.  At  times  a  number  of  malformations  are  found 
in  one  individual.  If  the  intermaxillary  process  fails  to  unite  with  the 
superior  maxillary  process,  a  failure  of  union  in  the  soft  parts  follows,  result- 
ing in  harelip.  It  may  be  complete  or  incomplete,  single  or  double.  The 
fissure  or  fissures  are  not  in  the  median  line,  but  correspond  to  the  line  of 
union  between  the  intermaxillary  and  superior  maxillary  bones.  In  double 
harelip  there  is  often  a  displacement  forward  of  the  intermaxillary  bone,  and 
fissure  of  the  nose  is  not  infrequently  seen  with  it.  In  these  cases  also  cleft 
palate  is  not  infrequently  a  complication.  Harelip  interferes  more  or  less 
with  nursing,  but  especially  if  complicated  with  cleft  palate.  Feeding  with 
a  spoon  is  not  successful,  as  the  food  regurgitates  through  the  nose.  These 
infants  are,  as  a  rule,  poorly  nourished,  and  if  they  live,  have  a  low  vitality. 
The  child's  strength  should  be  sustained  as  well  as  possible  for  a  few  weeks, 
when  a  plastic  operation  should  be  done. 

23 


354  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

Cleft  Palate. — This  consists  in  a  division  in  the  median  line  of  the  palate. 
It  results  from  a  failure  in  the  inward  growth  of  the  palatine  processes.  It 
may  affect  the  uvula,  the  soft  palate,  or  the  whole  roof  of  the  mouth.  When 
the  latter  condition  is  found,  it  is  not  rarely  associated  with  harelip.  Cleft 
palate  may  be  single  or  double.  It  interferes  seriously  with  nursing,  and  a 
soft-rubber  palate  should  be  attached  to  the  nipple  of  the  nursing-bottle  ; 
this  fits  into  the  cleft  and  enables  the  child  to  suck.  A  plastic  operation 
should  be  done  when  the  child  has  reached  the  age  of  two  or  three  years. 

Tongue-tie  (Anhyloglossia). — This  consists  in  a  shortening  of  the  frcenum 
lingua.  It  at  times  binds  the  tongue  to  the  floor  of  the  mouth  and  pre- 
vents its  protrusion  beyond  the  teeth.  It  interferes  with  suckling,  and  if 
not  corrected,  will  later  interfere  with  speech.  Treatment  consists  in  raising 
the  tip  of  the  tongue  with  a  finger  and  dividing  the  frenum  for  about  one- 
eighth  of  an  inch,  the  cut  being  directed  toward  the  floor  of  the  mouth. 
Any  further  separation  should  be  made  by  tearing  with  the  fingers. 

Congenital  occlusion  of  the  posterior  nares  is  rarely  met  with.  Con- 
genital cysts  are  met  with  in  the  tongue,  but  are  most  frecjtient  beneath  the 
tongue  and  in  the  floor  of  the  mouth. 

Deformities  of  the  lower  digestive  tract  may  occur.  Congenital  "  hour- 
glass "  constriction  of  the  stomach  occurs  but  rarely.  Obstructions  occur  in 
different  portions  of  the  small  bowel,  namely  duodenum,  jejunum,  and  ileum, 
more  frecpiently  in  the  latter  portion.  At  times  portions  of  the  intestine  are 
found  entirely  obliterated  or  represented  by  only  a  band  of  fibrous  tissue 
occupying  the  edge  of  the  mesentery.  Volvulus  and  hernia  may  be  the 
cause  of  obstruction.  Several  cases  of  perforation  of  the  intestines  are  recorded. 
Death  occurs  within  a  few  hours  of  birth.  The  sigmoid  flexure,  the  splenic 
flexure,  and  the  transverse  colon  were  the  seats  of  perforation.  The  cause 
is  tissue  necrosis,  presumably  due  to  an  accumulation  of  meconium.  The 
large  intestine,  sigmoid  flexure,  and  rectum  are  the  seats  of  various  malfor- 
mations. Obstruction  due  to  incomplete  development  is  the  commonest 
form.  In  imperforate  rectum  the  whole  rectum  is  absent  and  the  anus  usually 
imperforate.  The  colon  usually  terminates  in  a  blind  sac  opposite  the  sacral 
promontory  or  in  the  iliac  fossa.  In  imperforate  anus  the  rectum  is  fully 
formed  but  the  anus  is  completely  absent.  In  occlusion  of  the  rectum  the 
anus  is  perfectly  formed,  and  the  nature  of  the  case  is  frecpiently  not  dis- 
covered until  symptoms  of  intestinal  obstruction  appear,  and  an  examination 
is  made,  revealing  an  occluding  membrane  from  -J-  inch  to  1-^-  inches  above 
the  orifice. 

Umbilical  Hernia  ( E.v omphalos). — This  may  be  due  to  a  patulous  condi- 
tion at  this  point,  or  to  a  weakened  condition  of  the  structures  forming  the 
abdominal  wall  at  this  site.  Usually  it  is  not  a  severe  condition,  consisting 
in  the  protrusion  or  pouting  of  a  small  loop  of  intestine.  This  may  be  cor- 
rected by  a  small  pad  used  as  a  compress  and  secured  by  a  firm  abdominal 
binder.  The  prognosis  is  favorable.  In  the  severer  forms  a  plastic  oper- 
ation is  necessary  for  a  cure,  and  the  prognosis  of  these  cases  is  unfavorable. 


THE  PATHOLOGY   OF  PREGNANCY.  355 

Congenital  Inguinal  Hernia. — This  form  of  hernia  results  from  the 
vaginal  process  of  peritoneum  remaining  patulous.  While  the  condition  is 
most  common  in  infancy,  occasionally  it  does  not  develop  until  later  in  life, 
when  it  appears  suddenly. 

Generative  Organs. — Congenital  defects  are  more  common  in  the  male 
than  in  the  female.  In  the  female  they  are  not  usually  noticed  until  a  later 
period  in  life.  The  defects  of  the  female  consist  in  vaginal  and  uterine 
atresia,  with  uterine  and  ovarian  malformations.  The  deformities  of  the 
female  generative  organs  are  usually  caused  by  some  arrest  in  the  develop- 
ment or  a  failure  of  the  Mullerian  ducts  to  unite  in  embryonal  life.  The 
failure  to  unite  gives  rise  to  the  various  forms  of  double  formations  of  uterus 
and  vagina,  which  later  cause  abnormalities  in  pregnancy  and  labor.  A 
persistence  of  the  canals  of  Giirtner  sometimes  later  in  life  gives  rise  to  vagi- 
nal cysts,  while  the  ducts  of  the  AVolffian  body,  if  they  persist,  may  develop 
into  parovarian  cysts.  While  numerous  cases  of  cystic  ovarian  tumors  at 
birth  have  been  reported,  there  is  still  much  doubt  and  discussion  as  to  their 
embryonic  origin.  Pozzi  believes  that  all  cystic  ovarian  tumors  are  already 
formed  in  the  embryo.  This  applies  especially  to  the  dermoid.  J.  Bland 
Sutton  has  failed  in  all  his  studies  to  find  an  ovarian  dermoid  at  birth,  and 
knows  of  no  authentic  case. 

In  the  male  the  most  common  defect  is  phimosis.  This  consists  in  a 
prolongation  and  constriction  of  the  prepuce,  with  adherence  of  the  mucous 
membrane,  preventing  exposure  of  the  glans  penis.  This  condition,  if  not 
soon  corrected,  will  lead  to  enuresis,  with  a  tendency  to  spasms  and  mastur- 
bation. The  adhesions  should  be  separated  and  the  fore-kin  retracted  imme- 
diately after  birth  or  when  the  child  is  two  or  three  weeks  old.  The  foreskin 
should  be  retracted  daily  for  several  days,  and  sweet  oil  or  petrolatum  apjjlied 
to  prevent  adhesions  reforming.    Circumcision  may  be  required  in  some  cases. 

Malformations  of  the  Extremities. — Supernumerary  digits,  fingers,  or  toes 
is  another  form  of  malformation.  They  are  not  usually  fully  developed,  being  car- 
tilaginous in  structure.   They  may  be  ligated  and  excised  or  allowed  to  drop  oif. 

Syndactylism  is  a  congenital  union  of  the  digits  of  hand  or  foot.  This 
occurs  in  varying  degrees  from  a  firm  union  to  a  web  uniting  adjoining 
digits.  Treatment  consists  in  incision  and  maintaining  separation  until  the 
surfaces  are  sufficiently  healed. 

Talipes  or  club-foot  is  often  congenital,  and  occurs  more  frequently  in 
males  than  in  females.  It  is  due  to  the  long  retention,  in  utero,  of  the  foot 
in  a  certain  position.  The  position  may  have  been  due  to  an  insufficient 
amount  of  the  amniotic  fluid.  The  long-continued  retention  of  the  foot  in 
these  positions,  with  pressure  upon  the  soft  parts,  retards  the  progress  of 
growth  of  the  bones  and  tends  to  shortening  of  the  bones ;  thus  the  position 
becomes  fixed  (Landerer).  Talipes  varus  or  equinovarus  are  the  most  fre- 
quent varieties.  There  is  usually  some  weakness  and  paralysis  accompanying 
this  deformity.  The  muscles  of  the  affected  side  are  weakened,  while  their 
opponents  are  in  tonic  contraction. 


356  AM  ERIC  AX    TEXT-BOOK    OF    OBSTETRICS. 

Treatment  consists  in  proper  bandages  and  braces,  which  should  be  applied 
as  soon  as  the  deformity  is  discovered. 

Malformations  of  the  Circulatory  Apparatus. — The  malformations  of 
the  heart  are  the  most  common  ;  of  these,  persistence  of  the  foramen  ovale 
is  most  frequently  found.  Fetal  endocarditis,  with  its  consequent  valve 
lesions,  and  transposition  of  the  aorta  and  pulmonary  artery  also  occur. 
"  Reptilian  heart "  sometimes  occurs.  This  consists  in  a  rudimentary  septum 
between  the  ventricles,  and  resembles  the  arrangement  of  the  heart  in  the 
lower  forms  of  life,  hence  its  name.  Persistent  cyanosis  is  the  most  marked 
symptom  of  these  malformations,  and  frequently  the  fetus  is  not  viable  when 
born. 

Malformations  of  the  Brain  and  Cord. — -Meningocele  and  encephalocele 
are  tumors  consisting  of  the  protrusion  of  portions  of  the  cranial  contents 
through  a  suture  or  a  portion  of  the  skull  which  in  fetal  life  was  membranous. 
They  are  generally  single,  but  are  occasionally  multiple.  They  vary  in  size 
from  a  pea  to  that  of  the  head  itself,  and  usually  are  found  in  the  occipital 
region,  occasionally  at  the  root  of  the  nose  or  on  one  of  the  fontanels.  The 
prognosis  is  unfavorable. 

Spina  bifida  QvydrorracMs)  may  be  found  in  any  part  of  the  spinal  col- 
umn. It  is  a  congenital  malformation,  not  uncommon,  and  consists  in  the 
failure  of  the  lamina  of  one  or  more  vertebrae  to  unite,  allowing  the  protru- 
sion of  the  spinal  membranes,  which  form  a  tumor  containing  cerebrospinal 
fluid  and  some  of  the  spinal  nerves.  At  times  a  part  of  the  spinal  cord 
itself  has  been  found.  In  spina  bifida  a  hardened  lump  is  found  at  the 
greatest  prominence  of  the  tumor,  due  to  the  attachment  of  the  cauda  equina 
at  that  point.  Spinal  meningocele  does  not  contain  any  portion  of  the  cord, 
and  consists  onlv  of  the  spinal  membranes.  A  meningomyelocele  is  formed 
of  the  spinal  membranes  containing  a  part  of  the  cord  and  spinal  nerves. 
If  in  the  latter  protrusion,  the  spinal  canal  is  dilated,  forming  a  sac,  it  forms 
a  syringomyelocele. 

Hydrocephalus  is  not  common,  occurring  once  in  2000  pregnancies.  It 
consists  in  a  collection  of  serous  fluid  at  some  point  within  or  outside  the 
brain  substance,  and  prevents  closure  of  the  fontanels.  It  is  probably  due 
to  an  obscure  inflammation  of  the  cerebral  meninges.  According  to  Hirst, 
it  is  not  very  rare,  is  often  overlooked,  and  is  a  frequent  cause  of  ruptured 
uterus.  The  diagnosis  may  be  made  by  vaginal  examination,  by  abdominal 
palpation,  or  under  anesthesia  if  necessary,  inserting  the  hand  into  the  womb. 
Hydrocephalus  should  be  considered  in  those  cases  in  which  the  head  fails  to 
engage  in  an  apparently  normal  pelvis.  The  fluid  collection  forms  slowly 
and  distends  the  cranial  vault,  often  to  a  great  degree.  This  distention  and 
pressure  cause  at  times  a  parchment-like  thinness  of  the  cranial  bones,  so 
that  encephalocele  results  in  consequence  of  the  thinness.  A  characteristic 
deformity  is  produced  in  hydrocephalus.  The  head  is  wedge-shaped,  with 
the  base  upward ;  the  fontanels  and  sutures  are  widely  distended.  The 
fa^e   and   lower  portion  of   the   skull  retain  their  normal   proportions,  but 


THE  PATHOLOGY   OF  PREGNANCY.  357 

the  eyes  are  set  far  in  or  are  directed  obliquely  inward,  while  the  forehead 
protrudes. 

Bxencephalus  is  a  deformity  in  which  the  brain  is  present  but  the  cra- 
nial bones  are  not  developed.  In  anencephalus  there  are  no  brain  and  no 
cranial  development.  Pseudencephalus 
is  a  deformity  in  which  there  are  an  ab- 
sence or  no  development  of  the  bones  of 
the  cranium  and  a  rudimentary  brain. 
Acephalia  and  hemicephalia  are  rare  de- 
formities consisting  in  defective  formation 
of  the  skull;  the  defect  at  times  also  in- 
volves  the  spine.      The   skin   and   nerve 

.  .     .  iii  Fig.166.— Skull  (front  view)  in  fetal  rachitis; 

tissues  are  absent,  being  replaced  by  some  absence  of  frontal  bone, 

granulation  tissue.     The  etiology  has   not 

been  determined.  This  deformity  is  not  usually  viable  at  birth  ;  if  born 
alive,  it  soon  dies.  Microcephalia  is  a  deformity  with  a  very  small  skull, 
having  a  flat  and  receding  forehead.  Monstrosities  of  this  variety  have  been 
known  to  live  to  old  age ;  they  are  imbecile. 

Excessive  Development. — Cases  are  recorded  of  excessive  development 
of  the  fetus  in  which  the  weight  varied  from  14  pounds  to  28J  pounds.  Such 
a  weight  as  the  latter  is  very  rare.  The  most  frequent  cause  is  considered 
to  be  prolongation  of  pregnancy.  Other  causes  are  the  large  size  of  one 
or  both  parents  and  multiparity.  Prolongation  of  pregnancy  occurs  in 
a  certain  small  proportion  of  cases.  Every  day  it  is  prolonged  there  is  a 
consequent  increase  in  the  size  and  body-weight  of  the  fetus.  Hirst  *  advises 
the  termination  of  labor  not  later  than  two  weeks  beyond  the  normal  period 
of  gestation  in  order  to  avoid  the  dangers  and  difficulties  of  overdevelopment. 
While  some  cases  may  be  terminated  unnecessarily  at  this  time,  serious  dan- 
gers and  complications  will  oftener  be  avoided.  Some  parts  of  the  fetus  may 
be  excessively  developed,  especially  the  extremities,  and  the  fetus  not  be 
above  normal  weight.  In  these  cases  if  fingers  or  toes  should  be  so  much 
enlarged  as  to  prevent  labor,  amputation  is  necessary. 

Double  Formations. — The  cause  of  the  development  of  homologous 
twins  and  double  monsters  has  not  been  fully  determined.  It  has  been  gen- 
erally accepted  that  both  originate  from  one  blastula  of  the  yolk.  Whether 
the  blastodermic  membrane  presents  two  germinative  areas  which  later  fuse 
more  or  less  into  one  being,  or  one  area  which  becomes  more  or  less  divided, 
is  still  a  question  of  dispute.  Union  may  take  place  in  the  cephalic,  median, 
or  caudal  extremity  of  the  embryo  ;  they  are  accordingly  known  as  cephalop- 
agus,  thoracopagus,  and  ischiopagus.  There  are  many  variations  of  these 
classes.     Fig.  167  represents  an   interesting  specimen  of  thoracopagus. 

Maternal  Impressions. — The  popular  belief  in  maternal  impressions 
is  very  old.    It  can  be  traced  back  to  the  peoples  of  the  last  centuries  before 
the  dawn  of  the  Christian  era.     The  belief  is  that  a  pregnant  woman  may 
*  Text- Book-  of  Obstetrics,  p  520. 


358 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


Fig.  167.— Thor 


be  so  affected  by  strong  emotions — i.  c,  fear,  anger,  etc. — and  impressive 
.sights  that  markings  and  malformations  of  her  child  may  result  from  them. 
A  pregnant  woman  can  undoubtedly  be  influenced  to  such  a  degree  that  the 

shape,  size,  and  appearance  of  her  child 
will  be  affected,  and  there  is  more  than  a 
mere  coincidence  in  the  matter  of  fright 
and  shock  and  the  subsequent  markings 
and  malformations  in  the  child.  . 

The  strongest  argument  of  those  opposed 
to  the  theory  of  maternal  impressions  has 
been  that  there  is  no  direct  nerve  connection 
existing  between  the  mother  and  the  fetus 
in  utero,  Bankstone  *  says  that  the  scien- 
tific features  of  the  cell  element  of  life  is 
often  overlooked.  It  is  endowed  with  indi- 
vidual and  fixed  properties  of  the  physical, 
mental,  motor,  and  sensory  elements  of 
either  or  both  parents,  and  needs  only  the 
mother's  blood  properly  to  develop  it. 
The  blood  is  capable  of  carrying  impres- 
sions to  the  fetus,  just  as  the  mother's  milk 
is  under  certain  psychic  disturbances  capable  of  affecting  the  infant.  The 
maternal  nourishment  carries  not  only  nutrition  to  the  impregnated  ovum, 
but  also  psychic  impressions,  such  as  grief,  anger,  fright,  etc.  Direct  nerve 
communication  between  fetus  and  mother  is  not  necessary,  for  maternal 
impressions  can  be  carried  through  the  blood.  Von  Welsenburg,f  in  his 
work  on  this  subject,  states  that  he  considers  maternal  impressions  a  rare 
occurrence.  He  quotes  Welder,  of  London  :  "  It  is  scarcely  possible  to  esti- 
mate accurately  the  influence  of  the  emotional  relations,  when  the  exact 
explanation  of  their  action  is  not  known."  Other  and  further  causes 
than  the  impression  exist  for  the  changes  in  the  child's  body.  But  all 
these  causes  are  able  to  influence  the  child  only  through  the  medium  of 
the  mother's  body.  Further  he  states  that  the  pregnant  womb  becomes 
directly  influenced  through  psychic  alterations  in  the  mother,  as  shown  by 
miscarriages  after  fright  and  other  strong  emotions. 

Disturbances  of  circulation  in  the  womb  through  the  effect  of  maternal 
impressions  is  certain  and  accepted  by  most  authors.  Direct  disturbances  in 
the  nourishment  of  the  womb,  and  through  that,  in  the  fetus,  through  mater- 
nal impressions  are  not  at  all  improbable.  He  considers  the  influence  of  the 
nervous  system  upon  metabolism  a  very  strong  point  in  the  affirmative  argu- 
ment. The  metabolism  of  the  mother  exists  in  most  intimate  relation  with 
that  of  the  fetus,  and  every  change  in  the  mother's  metabolism  may  be 
reflected  in  that  of  the  fetus,  and  thus  be  a  cause  of  malformation. 

The  statistics  of  births  during   the   siege   of  Paris,  1870-71,   show   the 
*  Alabama  Med.  Journal,  Sept.,  1901.  f  Das  Versehen  der  Frauai,  Leipzig,  1899. 


THE  PATHOLOGY   OF  PREGNANCY.  359 

deleterious  effects  of  profound  shock,  destitution,  and  want  of  food.  Of  92 
children  born  during  the  siege,  64  had  slight  mental  and  physical  anomalies,  20 
were  weak-minded,  and  8  were  moral  imbeciles.  Among  the  opponents  of 
this  theory  Landau  *  is  very  decided  in  his  disbelief.  He  admits  that  great 
and  earnest  minds  have  studied  the  problem  and  have  brought  forward  many 
apparently  authentic  cases  in  support  of  the  primitive  belief.  But  great  minds 
have  erred  before,  and  he  believes  that  maternal  impression  is  and  remains  a 
superstition.  H.  F.  Lewis  f  holds  to  the  view  that  monsters  are  not  due  to 
maternal  impressions,  but  are  due  to  anomalies  of  development  in  the  ovum 
and  are  not  influenced  in  any  way  by  the  mental  condition  of  the  mother. 
The  strongest  blow  to  the  theory  of  maternal  impressions  is  dealt  by  the 
results  of  the  experiments  in  the  artificial  production  of  monsters.  Experi- 
ments upon  eggs,  fishes,  and  insects  have  produced  almost  all  varieties  of 
monsters.  He  believes  that  all  malformations  in  monsters  can  be  explained 
by  physical  and  mechanical  causes  remote  from  psychic  influences.  J.  G. 
Kiernan  J  also  takes  a  negative  view  of  the  influence  of  the  psychic  element 
in  the  causation  of  malformations. 

Impossible  cases  are  cited  in  support  of  maternal  impressions — for  in- 
stance, a  mother  who  had  been  frightened  by  a  bull  in  the  eighth  month  of 
her  pregnancy  gave  birth  to  an  infant  with  a  head  resembling  that  of  a  calf. 
This  malformation  was  due  to  change  taking  place  probably  in  the  first 
month  of  fetal  development,  and  was  caused  by  an  arrest  in  development. 
Norman  Bridge,  who  is  a  strong  disbeliever  in  this  theory,  says  that  "  there 
is  possibly  enough  in  this  theory  so  that  we  should,  on  account  of  the  com- 
fort of  the  pregnant  woman,  advise  her  not  to  indulge  in  violent  emotions  or 
to  see  peculiar  sights  or  to  do  anything  which  is  outside  the  proprieties  of 
life."  In  the  past  the  belief  has  been  so  largely  hedged  about  by  supersti- 
tion, and  so  many  cases  have  been  reported  in  support  of  it,  the  authenticity 
of  which  could  not  be  confirmed,  that  the  subject  has  come  to  be  greatly 
discredited  among  scientists  and  medical  men.  A  close  study,  however,  is 
convincing  that  there  exists  between  the  nervous  system  of  the  mother  and 
the  growing  mental  and  jjhysical  organization  of  the  fetus  an  unknown  in- 
fluence, which  in  rare  instances  does  result  in  marking  and  malformation  of 
the  child. 

Death  of  the  Fetus. — Syphilis  is  preeminently  the  most  common  cause 
affecting  the  ovum  in  the  early  stages  of  its  development,  and  also  in  many 
cases  causing  death  of  the  fetus  just  before  term.  Systemic  poisoning,  such 
as  produced  by  lead,  mercury,  alcohol,  and  tobacco,  and  apoplexy  of  the 
placenta,  membranes,  or  ovum,  are  also  quite  often  causes  of  the  death  of 
the  fetus. 

Diagnosis. — It  is  often  absolutely  impossible  to  make  a  positive  statement 
as  to  whether  the  fetus  is  alive  or  dead.  Several  symptoms  regarded  as 
determining  the  death  of  the  fetus  have  been  advanced  by  different  writers, 

* Monalssch.  f.  Gebin-t,  n.  Oynak.,  May,  1S99.  t  Am.  Jour-  Obfitet.,  July,  1S99. 

XJour.  Amer.  Med.  Assoc,  Dec.  9,  1899. 


360  AMERICAN   TEXT-BOOK    OE    OBSTETRICS. 

but  no  one  of  them  is  generally  considered  sufficient  evidence  to  justify  a 
positive  diagnosis.  However,  when  several  of  these  symptoms  are  found 
together,  it  is  strong  presumptive  evidence  that  such  is  the  case.  These 
symptoms  are  as  follows  : 

1.  Absence  of  fetal  heart-sounds  and  fetal  movements  as  ascertained  by 
auscultation  and  palpation. 

2.  Crepitus  obtained  by  the  palpation  of  a  macerated  skull.  In  this 
condition  the  fetus  has  been  dead  for  some  time,  and  the  bones  of  the  head 
have  become  very  movable. 

3.  A  decrease  in  the  cervical  temperature,  which  usually  is  about  one 
degree  above  the  normal  body  temperature. 

4.  An  absence  of  pulsation  in  the  umbilical  cord  for  at  least  fifteen  min- 
utes, or  in  the  precordium,  felt  by  inserting  the  hand  into  the  uterus.  These 
are  the  only  positive  signs  of  fetal  death. 

5.  Cessation  of  growth  and  a  diminution  in  the  size  of  the  uterus,  deter- 
mined by  careful  measurements  of  the  abdomen. 

6.  Disappearance  of  the  subjective  signs  of  pregnancy. 

7.  Peptonuria ;  peptone  in  the  urine  is  considered  by  some  writers  as  a 
sign  of  fetal  death,  but  Kaltheitz,*  in  his  investigations,  decided  that  it  is 
not  so.  It  is  a  physiologic  phenomenon  and  is  pathologic  only  when  found 
in  excess. 

8.  Disturbances  of  renal  functions,  such  as  albuminuria. 

9.  Appearance  of  milk  secretion  in  the  breasts. 

Changes  in  Structure  of  the  Fetus  after  Death. — These  to  a 
degree  depend  upon  the  period  of  development,  the  length  of  time  the  dead 
fetus  has  been  retained  in  the  body,  and  whether  there  has  been  a  rupture 
of  the  membranes  with  access  of  air. 

Absorption. — Absorption  occurs  only  when  death  has  occurred  before 
the  third  month.  The  embryft  has  become  macerated  and  absorbed  by  the 
liquor  amnii.  This  is  shown  in  the  thick,  gummy  condition  of  the  amniotic 
fluid. 

Maceration  {Foetus  Sanguinohntus)  is  probably  the  most  common  of  the 
postmortem  fetal  changes.  The  membranes  have  not  been  ruptured,  and 
the  change  consists  in  a  softening  of  the  skin  and  deeper  tissues.  The  skin 
of  the  fetus  is  wrinkled  and  soft  and  usually  discolored  brownish  or  livid. 
Bullte  containing  a  yellowish  fluid  frequently  are  found.  Red  patches  of 
corium  are  exposed  when  these  bulla?  are  ruptured.  The  tissues  are  soft  and 
edematous  ;  they  can  be  easily  separated  from  the  bones  ;  the  joints  are  very 
loose  ;  the  cranial  bones  are  very  freely  movable  and  widely  separated.  The 
placenta  and  membranes  are  softened  and  edematous.  The  umbilical  cord  is 
dark  and  spongy  and  does  not  exhibit  its  normal  coiling.  The  jelly  of 
Wharton  is  distributed  irregularly. 

Mummification. — A  change  which  occurs  before  the  membranes  are  rup- 
tured. The  fetus  is  shriveled,  shrunken,  and  dried  up.  It  is  grayish  or  yel- 
*  Deatsch.  med.  Wochen.,  1889,  No.  44. 


THE  PATHOLOGY   OF  PREGNANCY.  361 

lowish  in  color,  the  skin  being  like  leather  and  showing  the  outline  of  the 
skeleton.  When  such  a  fetus  is  retained  for  a  long  time  and  becomes  flattened 
by  pressure,  it  is  termed  foetus  papyraceus.  This  flattening  is  likely  to  be 
produced  in  a  twin  pregnancy  when  one  fetus  dies. 

Saponification. — The  fetal  structures  undergo  a  fatty  or  soapy  change 
and  have  a  peculiar  greasy  feel.  Adipoceration  is  a  different  degree  of  the 
same  process. 

Putrefaction  is  due  to  the  entrance  of  the  germs  of  decomposition.  It 
is  characterized  by  a  foul  odor  and  the  production  of  gas.  This  gaseous 
condition  is  known  as  physometra  or  tympanites  uteri. 

Suppuration  is  often  associated  with  putrefaction. 

Calcification. — When  the  tissues  of  a  dead  fetus  become  infiltrated  with 
lime-salts  they  become  hardened  and  stony.  Such  a  fetus  is  termed  a  litho- 
pedion.  Instances  are  recorded  in  which  such  a  fetus  has  been  retained  for 
many  years.  Lusk  cites  a  case  in  which  he  removed  a  calcined  fetus  thirteen 
years  after  pregnancy  occurred. 

Habitual  Death  of  the  Fetus. — Syphilis  is  by  far  the  most  frequent 
cause  of  habitual  death  of  the  fetus,  83  per  cent,  of  such  deaths  being  due 
to  syphilis. 

Chronie  Diseases  of  the  Mother. — Tuberculosis,  cancer,  diabetes,  nephritis, 
and  malaria  are  some  of  the  chronic  diseases  producing  fetal  death.  The 
mortality  of  the  children  of  nephritic  mothers  is  very  high — about  85  per 
cent,  of  such  children  are  born  dead  or  survive  but  a  short  time. 

Causes  Referable  to  the  Mother. — Metritis,  endometritis,  and  uterine  dis- 
placements, alterations  in  the  maternal  blood,  as  anemia,  plethora. 

Causes  Referable  to  the  Father. — Old  age,  chronic  poisoning,  phthisis, 
albuminuria.  Any  condition  producing  a  low  vitality  in  the  father  is  likely 
to  produce  a  low  vitality  in  the  fetus,  and  death  often  occurs  before  birth. 

Causes  Referable  to  the  Fetus  and  its  Annexes. — Recurring  deformities, 
anasarca.  Degenerations  of  the  placenta,  membranes,  and  cord,  with  extrava- 
sations of  blood.     Hydramnios   is  not  uncommon,  and,  when  present  in  a 


Fig.  168.— Knotted  cord  (Bidloo). 


marked  degree,  causes  fetal  death.     Knotting  and  compression  of  the  umbil- 
ical cord  causes  changes  in  the  circulation  which  affect  the  fetus. 

Habit  and  Heredity. — In  some  women  death  of  the  fetus  occurs  at  about 
the  same  period  of  the  gestation  in  succeeding  pregnancies.  Usually  no  cause 
can  be  found.  This  is  known  as  "  habitual  death,"  and  some  authors  ascribe 
it  to  syphilis,  maternal  anemia,  or  uterine  disease. 


302 


AMERICAN   TEXT- HOOK    OF    OBSTETRICS. 


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Gebhard  :  Pathological  Anatomy  of  the  Female 

Sexual  Organs,  Leipsie,  1899.  S.  Hirzel. 
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Hogan  :  Transactions  Southern  Surgical  Society, 

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Loviot :  Bulletins  et  Memoires   de   la   Societe 

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der  Deutscher  Gesell- 
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9.  Froinmel:    Perhandlum 
schaft  fur  Gynakologi 

10.  Eoutier  :  Annalesdi  >,,, 

11.  Strauck:  St.  Petersburg 

enschrift,  1892,  No.  id. 

12.  Phillips  :  Practitioner,  December,  1S88. 

13.  Pozzi:   Gazette  Medicate  de  Paris,  1890,  No.  21. 

14.  Ohlshausen  :  Zeitschrift  fur  Geburtshulfe  und 

Gynakologie,  1900,  Bd.'  xliii.,  H.  1. 

15.  Burckhard :  Zeitschrift  fur  Geburtshulfe,  1900, 

Bd.  xliii.,  H.  1. 

16.  Kelly:  American  Gynecological  Society,  1898. 

17.  Edebohls:    American  Journal  of    Obstetrics, 

May,  1891. 
IS.  Eobb:    American  Journal  of  Obstetrics,   Sep- 
tember, 1897. 

19.  Bourcart :  Annates  de  Gynecologic,  July,  1894. 

20.  Hofineier  :  Zeitschrift  fur  Geburtshulfe,  1894, 

Bd.  xxx.,  H.  1. 

21.  Ott:  Centralblatt  fiir  Gynakologie,  1889,  No.  18. 

22.  Gordon  :  Boston  Medical  Journal,  October  17, 

1889. 

23.  Staveley :    New   York  Journal  of  Gynecology 

and  Obstetrics,  1894,  No.  5. 

24.  Van  der   Veer :    Journal    American    Medical 

Association,  1892,  No.  19. 

25.  Fritsch  :   Centralblatt  fiir   Gyndiologie,   1899, 

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26.  Mittermaier:    Centralblatt    fiir    Gynakologie, 

1S99,  No.  1. 

27.  Fehlimj:   Monatsschrift  fiir  Geburtshulfe  und 

Gynakologie,  1895,  Bd.'ii.,  H.  5. 

28.  Fehliug :    Munchener    medicinische     Woehen- 

schrift, 1897,  Xo.  47. 

29.  Reckmann:  Centralblatt  fur  Gynakologie,  1897, 

No.  47. 

30.  Ohlshausen:  Berliner  klinische  Woehenschrift, 

1896,  No.  23. 

31.  Baeckner:  Archiv  fiir  Gynakologie,  Bd.  liii  , 

H.  1. 

32.  Beekmann  :  Zeitschrift  fiir  Geburtshulfe  und 

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33.  Stocker:   Centralblatt    fiir   Gynakologie,   1892, 

No.  32. 

34.  Coe:  American  Journal  of   Obstetrics,  April, 

1893. 

35.  Hernandez:  Annates  de  Gynecologic,  August 

and  September,  1894. 

36.  Borrmann  :  Zeitschrift  fiir  Geburtshulfe  und 

Gynakologie,  1900,  Bd.  xliii..  H.  2. 

37.  Auvard  :  Bulletins  de  la  Societe  Obstetricale  de 

Paris,  1889,  No.  5. 

38.  VonHerff:   Centralblatt  fiir  Gynakologie,  1891, 

No.  50. 

39.  Moller:     Centralblatt   fiir   Gynakologie,    1S92, 

No.  6. 


Taylor :  Medical  Record,  1891,  No.  9. 
Taylor :  Medical  Record,  1891,  No.  9. 
Ohlshausen :     Centralblatt    fiir    Gynakologie. 

1897,  No.  17. 
Leinziger  :   Centralblatt  fiir  Gynakologie,  1897, 

No.  18. 
Winter:     Zeitschrift    fiir     Geburtshulfe    and 

Gynakologie,  1900,  Bd.  xliii.,  H.  3. 
Edis  :    Transactions  Loudon  Obstetrical  Society, 

1882,  vol.  xxiv..  p.  304. 
Sinclair :  Medical  Chronicle,  May,  1896. 
Strogauowa :     Centralblatt   fiir    Gynakologie, 

1897,  No.  15. 

48.  Audebert  and  Sabrazes:    Annates  de   Gyne- 

cologic, April,  1897. 

49.  Sanger  aud    C'kiari :   Centralblatt  fiir    Gyna- 

kologie, June  13,  1891. 

50.  Sanger:    Centralblatt  fur    Gynakologie,   1894, 

No.  7. 

51.  Pehain :    Centralblatt  fiir   Gynakologie,    1900, 

No.  14. 

52.  Anders :     Munchener     medicinische     Woehen- 

schrift, 1899,  No.  5. 

53.  Krebs :   Monatsschrift  fiir    Geburtshulfe   und 

Gynakologie.  1900,  Bd.  xi.,  H.  5. 

54.  Solowij    and.    Krzyszkowski :    Monatsschrift 

fiir  Geburtshulfe  und  Gynakologie,  1900, 
Bd.  xii.,  H.  1. 

55.  Poten  and  Vassmer :  Archiv  fiir  Gynakologie, 

1900,  Bd.  lxi.,  H.  2. 

56.  Marcbesi :  Annali  di  Ostetricia  e  Ginecologie, 

1900,  No.  1  and  2. 

57.  Bacon  :  American  Journal  of  Obstetrics,  May, 

1895. 
5S.  Spencer:  Obstetrical  Society  of  London,  April  1, 
1S96. 

59.  Williams:  Johns   Hopkins   Hospital   Reports, 

1S95,  vol.  iv.,  No.  7  and  S. 

60.  Lindfors:   Centralblatt  fiir  Gynakologie,  1S97, 

No.  1. 

61.  Mouod  and  Chabry :  Revue  de  Gynecologie  e 

de  Chirurgie.  January  and  February,  1897. 

62.  Marchand:   Zeitschrift  fiir  Geburtshulfe  und 

Gynakologie,  1898.  Bd.  xxxviii.,  xxxix. 

63.  Peters :  Die  Einbettung  des  menschiichen  Eies, 

Leipzig  und  Wien,  1899. 

64.  Schmorl:  "Demonstration  eines  Syneytia- 

len  Schneidentumors,"  "  ATers.  d.  Natur- 
forscher  und  Aerzte  in  Braunschweig,"  ref. 
Centralblatt  fiir  Gynakologie.  1S97,  No.  40. 

65.  Davis  and  Harris:  American  Journal  of  Ob- 

stetrics. July,  1900. 

66.  Hermann  :   Transactions    London     Obstetrical 

Society,  1891,  vol.  xxxiii.,  p.  456. 

67.  Virchow  :  Archiv,  Bd.  xxi.,  S.  118. 

68.  Strassmann  :   Monatsschrift  fiir   Geburtshulfe 

und  Gynakologie,  Bd.  xix.,  S.  242. 

69.  Dohrn  :  Monatsschrift   fiir   Geburtshulfe  und 

Gynakologie,  Bd.  xxi.,  S.  375. 

70.  Gusserow:    Monatsschrift    fiir    Gebnrtshiilfe 

und  Gynakologie,  Bd.  xxvii.,  S.  321. 

71.  Klebs:    'Monatsschrift  fiir    Geburtshulfe   und 

Gynakologie,  Bd.  xxvii.,  S.  401. 

72.  Matthews  Duncan  :  Researches  in  Obstetrics, 

p.  290. 

73.  Dickey  :  Annals  of  Gynecology  and  Pediatrics, 

1891,  1S92.  5.  p.  6.  ' 

74.  Madurowicz:   Wiener  klinische  Woehenschrift, 

1S89,  No.  20. 

75.  Weiss  and  Schuhl :  Annates  de  Gynecologie, 

April,  1900. 

76.  Walla:    Centralblatt    fiir    Gynakoloqie,    1900,. 

No.  19. 


REFERENCE   LIST. 


363 


77.  Chiari:    Prager  medicinische  Wochenschrift, 

1889,  No.  21. 

78.  Doktor :  Centralblatt  fur  Gynakologie,  1899, 

No.  52. 

79.  Stroganow:   Monatsschrift  fiir  Geburtshulfe 

unci  Gynakologie,  1900,  Bd.  xii.,  H.  1. 

80.  Woodbridge :  Medical  News,  April  7,  1900. 

81.  Guerard:  Monatsschrift  fur  Geburtshulfe  und 

Gynakologie,  1899,  Bd.  x.,  H.  5. 

82.  Spencer :  British  Medical  Journal,  January 

13,  1900. 

83.  Schmit :  Monatsschrift  fur  Geburtshulfe  unci 

Gynakologie,  1900, 'Bd.  xii.,  H.  3. 

84.  Halbau  :   Centralblatt  fur  Gynakologie,  1900, 

No.  25. 

85.  Iwanow:   Centralblatt  fiir  Gynakologie,  1900, 

No.  26. 

86.  Cameron  :  British  Medical  Journal,  October 

14,  1899. 

87.  Burger:    Miinchener    medicinische     Wochen- 

schrift, 1896,  No.  25. 

88.  Scliutze:    Centralblatt  fiir  Gynakologie,  1898, 

No.  19. 

89.  Dakiu  :     Transactions   Obstetrical  Society  of 

London,  vol.  xl..  Part  1. 

90.  Orthrnaim  :    Monatsschrift  fiir  Geburtshulfe 

unci  Gynakologie,  1898,  Bd.  vii.,  H.  4. 

91.  Pee:  Centralblatt fur  Gynakologie,  1897,No.l2. 

92.  Ludwig:     Wiener    klinische     Wochenschrift, 

1897,  No.  12. 

93.  Queisner  :  Centralblatt  fiir  Gynakologie,  1895, 

No.  51. 

94.  Discbler :  Archie  fiir  Gynakologie,  Bd.  Ivi., 

H.  1. 

95.  Jellingbaus:  Archiv  fiir  Gynakologie,  1897, 

Bd.  Ivi.,  H.  1. 

96.  Bovee :     American     Journal    of     Obstetrics, 

March,  1893. 

97.  Brown :    American    Journal    of     Obstetrics, 

December,  1896. 

98.  Hypes:    American     Journal     of     Obstetrics, 

'December,  1896. 

99.  Reissing  :   Centralblatt  fiir  Gynakologie,  1895, 

No.  2. 

100.  Albers-Schoenberg :   Centralblatt  fiir  Gyna- 

kologie, 1894,  No.  48. 

101.  Coe:  American  Journal  of   Obstetrics,  May, 

1891. 

102.  Coe:  American  Journal  of  Obstetrics,  May, 

1891. 

103.  Hektoen  :  American   Journal  of   Obstetrics, 

July,  1892. 

104.  Slechta  :  Der  Frauenarzt,  1891,  H.  6.  7. 

105.  Lbblein  :  Centralblatt  fiir  Gyniiko/ogie,Hareih, 

1892,  Bd.  xix.,  S.  200. 

106.  Noble  :    Transactions  American  Gynecological 

Society,  1891,  vol.  xvi.,  p.  484.' 

107.  Noble  :   Transactions  American  Gynecological 

Society,  1891,  vol.  xvi.,  p.  484.' 

108.  Coe:  American  Gynecological  Journal.  1891, 

No.  9. 

109.  Thomson:    Deutsche    medicinische    Wochen- 

schrift, 1889,  No.  44. 

110.  Polaillon  :  Archives  de  Tocologie  et  cle  Gyne- 

cologic T.  xix.,  p.  729. 

111.  Ruse:'    Centralblatt  fiir    Gynakologie,    1890, 

No.  30. 

112.  Schroeder,     Olshansen,     and     Flaischlen : 

Zeitschrift   fiir    Geburtshulfe,    1894,    Bd. 
xxi^.. 

113.  Dsirne:   Archie  fiir  Gynakologie.  Bd.   xlii., 

S.  415. 

114.  Mangiagalli  :     Berliner    klinische     Wochen- 

schrift, 1894,  No.  21. 

115.  Acconci :   "Dei  cistome  ovarici  in  rapporto 

alle  funzioni  generative,"  Milano,  Tipogr. 
Bechiei,  1889. 


116.  Terrilou:  Archives  de  Tocologie,  April,  1688. 

117.  Fehling:  Monatsschrift  fiir  Geburtshulfe  unci 

Gynakologie,  1900,  Bd.  xii.,  H.  4. 

118.  Kreutzmaun :     American    Journal    of     Ob- 

stetrics, February,  1901. 

119.  MacNaugliton  Jones :    Transactions    Obstet- 

rical Society  of  London,  1900,  p.  140. 

120.  Bland    Sutton:    The   Lancet,    February  9, 

1901. 

121.  Ward  :    Transactions   Pathological  Society  of 

London,  1853,  vol.  v.,  p.  219. 

122.  Kerswill:    British    Medical  Journal,    1880, 

vol.  ii.,  p.  83. 

123.  Brewer:    Transactions  Obstetrical  Society  of 

London,  vol.  xx.,  p.  184. 

124.  Berry :    Transactions    Obstetrical   Society   of 

London,  vol.  vii.,  p.  263. 

125.  Griffith  :    Transactions  Obstetrical  Society  of 

London,  vol.  xxxiii.,  p.  140. 

126.  Sutton  :  Medical  Press   and    Circular,  1892, 

vol.  ii.,  p.  94. 

127.  Edward:  The  Lancet,  October  5,  1861,  p.  336. 

128.  Fenger:    American    Journal    of    Obstetrics, 

September,  1891. 

129.  Engstrom :  Annates  de  Gynecologie,  October 

and  November,  1890. 

130.  Hohl :  Archiv  fiir  Gynakologie,  Bd.  liii.,  H.  2. 

131.  McCone :    American    Journal   of    Obstetrics, 

November,  1897. 

132.  Byford :    American    Journal    of    Obstetrics, 

August,  1893. 

133.  Mainzer:    Miinchener  medicinische    Wochen- 

schrift, 1895,  No.  48. 

134.  Isirne:    Archiv  fiir    Gynakologie,   Bd.  xlii., 

part  3. 

135.  Hall :  American  Journal  of  Obstetrics,  March, 

1895. 

136.  Kreutzmann  :  American  Journal  of  Obstet- 

rics, 1S92,  p.  204. 

137.  Ebrendorfer :   Archiv  fiir   Gynakologie,   Bd. 

xxxiv.,  H.  1. 

138.  Winter:    Zeitschrift   fiir    Geburtshulfe.    Bd. 

xiv.,  H.  2. 

139.  Williams:    American  Journal  of  Obstetrics, 

December,  1898. 

140.  Hofmeier :    Deutsche    medicinische    Wochen- 

schrift, 1891  ;  Berliner  klinische   Wochen- 
schrift, 1898,  No.  46. 

141.  Kronig:    Miinchener    'medicinische     Wochen- 

schrift, 1900,  No.  1. 

142.  Waltbard :    Archiv    fiir    Gynakologie,    Bd. 

xlviii.,  H.  2. 

143.  Menge  und  Kronig:  Die  Bacteriologie  des 

weibliclien  Genitol-Kanals,  Leipzig,  1897. 

144.  Menge  und  Kronig:   Centralblatt  fiir  Gyna- 

kologie, 1900,  No.  5. 

145.  Doderlein :    Das    Scheidensecret    unci    seine 

Bedeutung  fur  das  Puerperal fieber,  Leip- 
zig, 1892.' 

146.  Friedrich :  Centralblatt  fiir  Chirurgie,  1899. 

No.  27. 

147.  Kottmann:  Archiv  fiir  Gynakologie,  Bd.  lv., 

H.  3.   1898. 

148.  Sticher:    Zeitschrift    fiir    Geburtshulfe   unci 

Gynakologie.  1900.  Bd.  xliv.,  H.  1. 

149.  Rissmann  :  Centralblatt  fiir  Gynakologie.  1892, 

Bd.  xxiv..  S.  452. 

150.  Virginia  Medical  Monthly.  1888-89,  vol.  xv., 

p.  670. 

151.  Hirst :  American  Journal  of  Obstetrics,  July, 

1893. 

152.  Martin:  Deutsche  medicinische  Wochenschrift, 

1889,  No.  39. 

153.  Treub :  Nederlandsch  tijdschrift  voor  Verlos- 

knnde  en  Gynakologie,  Jabrg.  iii.,  No.  3. 

154.  Gotrschalk:    Archiv   fiir   Gynakologie,    Bd. 

xlvi.,  H.  2. 


364 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


155.  Barbour:  Edinburgh  Medical  Journal,   Sep- 

tember, 1894. 

156.  Cohnstein :    Archiv   fiir    Gynakologie,    Bd. 

xxxiii.,  H.  1. 

157.  Benckiser :      Centralblatt    far    Gynakologie, 

1887,   No.  51. 

158.  Giles:  British  Gynecological  Journal,  Novem- 

ber, 1899. 

159.  Sinclair :  British  Medical  Journal,  December 

15,  1900. 

160.  Kerr :    British   Medical   Journal,   April    14, 

1900. 

161.  Seeligmann :    Centralblatt   fur    Gynakologie, 

1901,  No.  5. 

162.  Moucket:    Annates   de    Gynecologic,    T.  iv., 

December,  1900. 

163.  Davis:  International  Clinics,   1894.  vol.  iii., 

S.  4,  p.  275. 

164.  Trantenroth :    Zeitschrift  fur    Geburtshulfe 

and  Gynakologie,  1894,  Bd.  xxx.,  H.  1. 

165.  Fischer  :  Prager  medicinische  Woehenschrift, 

1892,  No.  17. 

166.  Schauta :  International  klinische  Rundschau,, 

1892,  No.  27. 

167.  Meyer:    Zeitschrift   fur    Geburtshulfe,    Bd. 

xvi.,  H.  2. 

168.  Lantos :  Archiv  fiir  Gi/uiikoloiiie.  Bd.  xxxii., 

H.  3. 

169.  Herman:  Lancet,  January  13,  1894. 

170.  Boudin  :  Journal  de  Medicine  de  Paris,  1893, 

No.  22. 

171.  Koblanck  :  Zeitschrift  fiir  Gynakologie,  1894, 

Bd.  xxix.,  S.  268. 

172.  Eklund :    American    Journal   of    Obstetrics, 

October,  1896. 

173.  Utley :  American  Journal  of  Obstetrics,  Sep- 

tember, 1S95. 

174.  Saft :  Archiv  fiir  Gynakologie,  Bd.  Ii.,  H.  2. 

175.  Bitchie:    British  Medical  Journal,  January 

20,  1900. 

176.  Palmer :    American    Journal    of    Obstetrics, 

September.  1892. 

177.  Berberoff:    Vrach,  1893,  No.  16. 

178.  Voituriaz :  Archives  de  Tocologie,  1890,  No. 

12. 

179.  Randolph  :  Bulletin  Johns  Hopkins  Hospital, 

1S94,  vol.  v.,  No.  41. 

180.  Schroeder  :  Lehrbuch  der  Geburtsftiilfe,  1891. 

181.  Gow:     Edinburgh    Medical     Journal,     1888, 

part  2. 

182.  Phillips:    Transactions  Obstetrical  Society  of 

London.  1899,  part  4. 

183.  Gosset   and   Mouchotte:    Annates  de   Gyne- 

cologic, November,  1900. 

184.  Storer:  Boston  Medical  and  Surgical  Journal, 

1892,  vol.  cxxvii.,  pp.  377,  379. 
1S5.  Jardrin :    Glasgow    Medical    Journal,    1892, 
vol.  xxxvii.,  417,  422. 

186.  Sutugin :    Zeitschrift  fiir   Geburtshulfe,   Bd. 

xxiv..  S.  286. 

187.  Budin  :  Progres  Medicate,  1888,  No.  2  and  3. 

188.  Larkin :  British  Medical  Journal,  1900,  No. 

2063. 
139.  Sprigg :    American    Journal    of     Obstetrics, 
September,  1896. 

190.  Coe:  American   Journal   of  Obstetrics,   Feb- 

ruary, 1891. 

191.  Marx :  American  Journal  of  Obstetrics,  Jan- 

uary, 1893. 

192.  Kuhnow  :  Arehir  fiir  Gynakologie,  Bd.xxxv., 

H.  3. 

193.  Driver:  Boston  Medical  and  Surgical  Journal, 

September  15,  1887. 

194.  Diihrssen :     Archiv    fiir     Gynakologie,     Bd. 

xliii.,  H.  3. 

195.  Budin:   La  Semaine  Medicate.  1893,  T.  xix., 

p.  141.      • 


196.  Charpentier :    Archives  de    Tocologie,   1892, 

No.  2. 

197.  Prutz :    Zeitschrift    fiir     Geburtshulfe,    Bd. 

xxiii.,  H.  1. 

198.  Pilliet   and    Delansorme :     Bulletin    de   la 

Societe  Anatomique  de  Paris,  1892,  No.  8. 

199.  Fischer  :  Prager  medicinische  Woehenschrift, 

1892,  No.  17. 

200.  Blanc:  Lyons  Medicate,  1890,  No.  38. 

201.  Papillon  and  Audain  :  Bulletin  de  la  Societe 

Anatomique  de  Paris,  1891,  T.  vi.,  p.  353. 

202.  Kotfer    and    Kundrat :      Wiener     klinische 

Woehenschrift,  1891,  Bd.  xx. 

203.  Gerdes :     Munchener     mediciuishe     Woehen- 

schrift, 1892,  No.  22. 

204.  Tanner  and  Chambrelent :  Annates  de  Gyne- 

cologic, November,  1892. 

205.  Lang :  Archives  de  Tocologie,  1892,  No.  11. 

206.  Herman  :  American  Journal  of  the  Medical 

Sciences,  November,  1891,  p.  485. 

207.  Davis :    American   Journal   of    the    Medical 

Sciences,  February,  1894,  p.  147. 

208.  Gustav  Braun :   Wiener  medicinische  Presse, 

1888,  No.  19. 

209.  Blanc:    Annates    de    Gynecologie,    1891,    T. 

xxxvi.,  p.  15. 

210.  Blanc :  Lyons  Medicate,  1890,  No.  38. 

211.  Van  Santvoord  :  Medical  Record,  1891,  vol. 

xl.,  p.  197. 

212.  Thomson  :    Deutsche    medicinische    Woehen- 

schrift, 1889,  No.  44. 

213.  Koettnitz:     Centralblatt    fiir     Gynakologie, 

1888,  No.  48,  S.  778. 

214.  Gessner  :   Centralblatt  fiir  Gynakologie,  1900, 

No.  35. 

215.  Levinowitsch:    Centralblatt  fiir  Gynakologie, 

1899,  No.  46. 

216.  Stroganoff:  Zeitschrift  fiir  klinische ■  Medicin, 

Bd.  xxxix.,  H.  5,  6. 

217.  Fothergill  and  Stenhouse  :  British  Medical 

Journal,  March  3,  1900. 

218.  Savory  :   Transactions   Obstetrical  Society  of 

London,  1899. 

219.  Vanderhoeven :   L'Obstetriqne,  1899,  No.  5. 

220.  Davis:  American  Journal  of  Obstetrics,  De- 

cember, 1893. 

221.  Marx  :  Medical  News,  June  30,  1900. 

222.  Stewart :    American   Journal   of    Obstetrics, 

1897-98. 

223.  Diihrssen  :  Archiv   fiir  Gi/nakologie,  Bd.  xl., 

S.  328. 

224.  Laulame    and    Chambrelent:     Annates    de 

Gynecologie,  1890,  p.  253. 

225.  Ludwig    and    Savory:     Monatsschrift    fiir 

Geburtshulfe  und    Gynakologie,   Bd.  i.,   S. 
466. 

226.  Volhard  :  Monatsschrift  fiir  Geburtshulfe  und 

Gynakoloaie,  Bd.  v.,  S.  411. 

227.  Saft:    Archiv    fiir    Gynakologie,    Bd.    ]i..    S. 

207. 

228.  Schmorl :   Archiv   fiir   Gynakologie,   Bd.  xl., 

S.  329. 

229.  Massen:   Centralblatt  fiir  Gynakologie,   1895, 

S.  1107. 

230.  Kronig:  Centralblatt  fiir  Gynakologie.  1894) 

S.  375. 

231.  Tridondani :  Annali  di  Ostetricia  e  Gynecol- 

oaie.  1901,  No.  1. 

232.  Griffith  and  Eden  :    Transactions  Obstetrical 

Society  nf  London.  1899,  vol.  xli.,  part  2. 

233.  Alfieri:  Annali  di    Ostetricia  e  Gynecologie, 

1900,  No.  12. 

234.  Dewar :  Scottish  Medical  and  Surgical  Jour- 

nal, February,  1901. 

235.  Ballantyne:    Scottish    Medical  and   Surgical 

Journal.  July,  1900. 

236.  Therapeutic  Gazette,  September  15,  1899. 


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365 


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1900,  No.  2. 
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Bd.  lxiii.,  H.  1,2. 
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1891,  Bd.  xxix.,  S.  353. 
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1388. 
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p.  279. 
Gairdner  :  Glasgow  Medical  Journal,  1870. 
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Bd.  xx vi. 
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Society,  1SS2,  vol.  xxiv.,  pp.  256-285. 
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colo,  Memoire  Original!,  1891,  No.  2. 


277.  Fry :    Transactions    American    Gynecological 

Society,  1891,  vol.  xvi. 

278.  Hehir  :  Indian  Medical  Gazette.  March,  1S92. 

279.  Feinberg:  Centraiblatt  fiir  Gynakologie,  1890, 

No.  7. 

280.  Davis :    Transactions  American  Gynecological 

Society,  1894,  vol.  xix.,  p.  110. 

281.  Liudenmann :    Centraiblatt  fiir    Pathologie, 

1892,  No.  15. 

282.  Copeman:  "A  Novel  Treatment  of  Obsti- 

nate Vomiting  in  Pregnancy,"  British 
Medical  Journal,  May  15,  1875. 

283.  Grant:     Montreal    Medical    Journal,    1891, 

vol.  xix. 

284.  Eoland  :  Nouvelles  Archives  d'Obstetrique  et 

de  Gynecologic,  1893,  No.  6. 

285.  Blanc:  Archives  de  Tocologie,  No.  6.  193. 
2S6.  Kingman:  Boston  Medical  and  Surgical  Jour- 
nal, vol.  lxxvii.,  p.  427. 

287.  Ahlfeld  :   Centraiblatt  fiir  Gynakologie,  1891, 

No.  17. 

288.  Gunther :   Centraiblatt  fiir  Gynakologie,  1888, 

No.  29. 

289.  Sanger  and  Henning :   Miinchener  medicin- 

ische Wochenschrift,  1S8S,  No.  28. 

290.  Bacon  :    American   Journal    of    the    Medical 

Sciences,  June,  1898. 

291.  Kiihne  :  Monatsschrift  fur  Geburtshiilfe  and 

Gyndkolcaie,  1899,  Bd.  x.,  H.  4. 

292.  Solowieff:   Centraiblatt  fiir  Gynakologie.  1892, 

S.  492. 

293.  Eulenberg :    Deutsche   medicinische    Wochen- 

schrift, 1895,  S.  140. 

294.  Schaeft'er:  Centraiblatt  fiir  Gynakologie,  1897, 

No.  12. 

295.  Davis :  American  Journal  of  Obstetrics.  July, 

1894. 

296.  Davis:  American  Journal  of  Obstetrics,  July, 

1900. 

297.  Davis  and  Harris  :  American  Journal  of  Ob- 

stetrics, Julv,  1900. 

298.  Schaeffer :  Ae'rstliche  Praxis,  1S99.  No.  1-4. 

299.  Klein :     Zeitschrift    fur    Geburtshiilfe     und 

Gynakologie,  1S98,  Bd.  xxxix.,  H.  1. 

300.  Reynolds :     Boston    Medical     and     Surgical 

Journal,  June  2,  1S98. 

301.  Goft'e:  American  Journal  of  Obstetrics,  Julv, 

1891. 

302.  Merle:  UObstetrique,  May  15,  1900. 

303.  MacKinnon  :  American  Journal  of  Obstetrics, 

February,  1891. 

304.  Kehrer  :   Centraiblatt  fiir  Gynakologie,  1896, 

No.  15. 

305.  Florentine:  American  Gynecological  Journal, 

1892,  vol.  ii.,  p.  149. 

306.  Clay:    Chicago   Medical   Standard,   1891,   p. 

29. 

307.  Johnston  :   Virginia  Medical  Monthly,  1889, 

vol.  xv..  p.  140.  See  also  Lomer,  "  Ueber 
die  Bedeutung  des  Icterus  Gravidarum 
fiir  Mutter  und  Kind."  Zeitschrift  fiir 
Geburtshiilfe,  Bd.  xiii..  H.  1.  S.  169." 

308.  Davis  :  Philadelphia  Medical  Journal,  March 

9,  1901. 

309.  Matthews  Duncan  :  Lectures  on  Diseases  of 

Women,  third  edition,  p.  295. 

310.  Winter:  Transactions  Washington  Obstetrical 

Society.  l*s9-90,  vol.  iii.,  p.  1. 

311.  Robert  Koch:  -^f.  Petersburger  medicinische 

Wochemchrift,  1893.  No.  10. 

312.  Mixter:  Boston  Medical  and  Surgical  Journal, 

1891,  No.  27. 

313.  Pinard:  Annates  de  Gynecologic,  May.  1900. 

314.  Abrahams:  American  Journal  of  Obstetrics, 

February,  1897. 

315.  Marx :     American     Journal     of     Obstetrics, 

August,  1898. 


3G(5 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


316.  MeArtkur:  American  Journal  of  Obstetrics, 

February,  1895. 

317.  Pinard:  Annates   de   Gyneeologie,  T.  xlix., 

1898. 

318.  Lantos:  Archie  fiir  Gyniikologie,  Bd.  xxxii., 

H.  3. 

319.  Thomson :     Deutsche    'medicinische    Wochen- 

schrift, 1899,  No.  44. 

320.  Koettnitz :    Deutsche   medicinische    Wochen- 

schrift,  1899,  No.  44. 

321.  Elliott:   Birmingham  Medical  Review,  1892, 

vol.  xxxii.,  p.  1. 

322.  Haberliu :  Centralblatt  fiir  Gynakologie,  1890. 

No.  26. 

323.  Dudner :    Munchener   medicinische    Wochen- 

schrift, 1890,  No.  31,  32. 

324.  Narse  :  Deutsche  Archie  fiir  Gynakologie,  Bd. 

x.,  S.  315. 
325   Wiuckelmann  :       Inaugural      Dissertation, 
Heidelberg,   1888. 

326.  Schroeder:    Archie  fiir    Gynakologie,    1890, 

Bd.  xxxix.,  H.  2. 

327.  Meyer :  Archie  fiir   Gynakologie,   1S87,  Bd. 

xxxi.  H.  1. 

328.  Ingersre'ff:  Centralblatt  fiir  Gynakologie,  1879, 

No.  26. 

329.  Fehling :      Verhandlungen    der     Deutschen 

Gesellschaft,  1886,  1.  Sitzung. 

330.  Meyer:  hoc.  eit. 

331.  Gusserow  :    Archie  fiir    Gynakologie,    1871, 

Bd.  ii.,  S.  218. 

332.  Bischotf  and    Biermer :    Corresporidenzblatt 

fiir  Scliweizer  Aerzte,  1*72. 

333.  Cameron  :  American  Journal  of  the  Medical 

Sciences,  January,  1888  :  November,  1890. 

334.  Sanger  :  Archie  fiir  Gyniikoloqie,  Bd.  xxxiii., 

H.  2. 

335.  Davis :    Transactions  American  Gynecological 

Society,  1891,  vol.  xvi. 

336.  Laubenberg :  Archiv  fiir  Gynakologie,  1891, 

Bd.  xii.,  H.  3. 

337.  Phillips  :     Transactions     London    Obstetrical 

Society,  1891,  vol.  xxxiii.,  p.  390. 

338.  Kaezma'rskv  :   Kliuische  Mittheiluuq  aus  der 

I.  Geburt'shiilfe  Klinik,  Buda-Pes'th,  1834, 
S.  178. 
339    Dohrn  :  Archiv  fiir   Gynakologie,   1874,   Bd. 
vi.,  S.  486. 

340.  Osier  :  Boston  Medical  and  Surgical  Journal, 

November*.  l--s. 

341.  Blumivirh:    Archiv  fiir   Gyniikologie,    1899, 

Bd.  lix.,  H.  3. 

342.  Istria:  "  De  la  grossesse  cousideree  couime 

cause  derendoearditeehronique,"  These, 
Paris,  1876. 

343.  Marshall :    "  Du  retrecissement  mitral,  sa 

frequence   plus  grande   chez   la  femme 
quechezl'homme,  I.,''  These,  Paris,  1879. 

344.  Mackuess:  Edinburgh  Medical  Journal,  1890, 

p.  123. 

345.  Merklen  :  La  Semaine  Medicate,  1892,  T.  xii., 

p.  274. 

346.  Pinard  :  Medical  Press,  1898,  No.  3065. 

347.  Martin :  Medical  Press  and    Circular,  1886, 

vol   ii.,  p.  328. 

348.  Bobertson  :  London  Lancet,  1891,  p.  487. 

349.  Schauta:  Internationale klinische  Rundschau, 

1892,  vol.  vi. 

350.  Cumston :   American  Journal  of  Obstetrics, 

October,  1899. 

351.  Hirigoyen  :  Memoirs  et  Bulletins  de  la  SocUte 

de  Medecine  et  de  Chirurgie  de  Bordeaux, 
1886,  T.  xv.,  p.  335. 

352.  Besnier :    Journal  de  Medicine,   November, 

1890. 

353.  Murray  :   Transactions  American  Gynecologi- 

cal Society,  1897. 


354.  Fehling :   Munchener   medicinische    Wochen- 

schrift, 1897,  No.  47. 

355.  Beckmann :    Centralblatt   fiir    Gynakologie, 

1897,  No.  47. 

356.  Coe :  American  Journal  of  Obstetrics,  April, 

1893. 

357.  Findlay  :   Obstetrical  Gazette,  1889,  vol.  xii. 

358.  Giglio :    Centralblatt   fiir   Gyniikologie,   1890, 

No.  46. 

359.  Bovd  :  Annals  of  Gynecology  and  Pediatrics, 

1891,  vol.  v. 

360.  Le  Page :    Transactions  Society  of  Obstetrics 

and  Gynecology  of  Paris. 

361.  Smith  :    Transactions  Washington  Obstetrical 

Society,  1889-90,  vol.  ii. 

362.  Cohn  :    Centralblatt    fiir    Gynakologie,    1888, 

No.  48. 

363.  Lonier :    Centralblatt  fiir   Gyniikologie,  1S89, 

No.  48. 

364.  Gautier :    Annates   de    Gyneeologie,   1879,   p. 

321. 

365.  Salus:    Prager    medicinische    Wochenschrift, 

1899,  No.  17. 

366.  Jardine  :  British  Medical  Journal,  April  27, 

1901. 

367.  Milligau:  Edinburgh  Medical  Journal,  Julv, 

1893. 

368.  Meyer :     Zeitschrift    fiir    Geburtshiilfe   und 

Gynakologie,  Bd.  xiv.,  H.  2. 

369.  Eemv:    Archives    de    Tocologie,    1894,    No. 

6. 

370.  Mann  :  London  Lancet,  1891,  p.  610. 

371.  Wallich :    Annates    de    Gyneeologie,    June, 

1889,  p.  439. 

372.  Klautsch :  Munchener  medicinische   Wochen- 

schrift, 1S92,  No.  48. 

373.  Vinay :  Archives  de  Tocologie,  1893,  No.  3. 

374.  Markus :  Prager  medieinishe   Wochenschrift, 

1890,  No.  21. 

375.  Dakin :      Transactions     London     Obstetrical 

Society,  vol.  xxxiii.,  p.  163. 

376.  Thomas :   Johns   Hojikins  Bulletin,  May  and 

June,  1895. 

377.  Stocker:   Centralblatt  fiir  Gyniikologie,  1892, 

No.  32. 

378.  Flaischlen :     Centralblatt   fiir    Gynakologie, 

1892,  No.  10. 

379.  Hofmeier  :  Zeitschrift  fiir  Geburtshiilfe  und 

Gynakologie.  1900.  Bd.  xlii.,  H.  3. 
3S0.  Pobedinskv:  Monatsschrift  fiir  Geburtshiilfe 

und  Gyniikologie,  1900,  Bd.  xii.,  H.  3. 
331.  Leopold  :    American  Journal  of   Obstetrics, 

May,  1895. 

382.  Pagenstecher :   Centralblatt  fiir  Gynakologie, 

1900.  No.  4. 

383.  Werder :    American    Journal  of    Obstetrics, 

September,  1893. 

384.  Dsirne:  Archiv  fiir  Gynakologie,  Bd.  xliii., 

H.  3. 
3S5.  Polaillon  :  Bulletin  de  I' Academic  de  Mede- 
cine, Paris,  1892.  T.  xxviii.,  p.  146. 

386.  Kreutzman :      Occidental     Medical     Times, 

August,  1892. 

387.  Isirne :    Archiv    fiir    Gynakologie,  Bd.  xlii., 

H.  3. 

388.  Kreutzmann  :    American  Journal  of  Obstet- 

rics, August,  1892. 

389.  King:  American  Journal  of  Obstetrics,  July, 

1893. 

390.  Eosenwasser :  American  Journal  of  Obstetrics, 

December.  1893. 

391.  Doran  :   Transactions  London  Obstetrical  So- 

ciety, 1891,  vol.  xxxiii.,  p.  112. 

392.  Tiffany:      Transactions     American    Surgical 

Association,  1888,  vol.  vi. 

393.  Belin :    Bulletin    Medical    du    Nord,    1878, 

vol.  xvii. 


REFERENCE   LIST. 


567 


394.  Richard:   Bulletin  Medical  du  Nord,  1878, 

vol.  xvii. 

395.  Harris :  American  Journal  of  Obstetrics,  vol. 

xx.,  p.  673. 

396.  Corey:    American  Practitioner,  September, 

1878. 

397.  Bydygier :  Proceedings  Congress  German  Sur- 

geons, 1867,  No.  12. 

398.  Petit:   Thesis,  1876. 

399.  Keelau :    British    Medical    Journal,    18S7, 

p.  825. 

400.  Prozowsky :   Vrach,    St.    Petersburg,   1879, 

No.  6. 

401.  Bancroft :    Medical   and   Surgical    Reporter, 

1876,  vol.  xxxiv. 

402.  Lihotzkv:  Centralblatt  fur  Gyniikologie,  1892, 

No.  24,  S.  4S9. 

403.  Milner  :  Medical  News,  vol.  lxi.,  pp.  243,  244. 


404.  Neugebauer:    Centralblatt  fur  Gyniikologie. 

1890,  S.  88. 

405.  Fancou :  Journal  des  Sciences  Medicates  de 

Lille,  18S3,  S.  241. 

406.  Tiffany:   Transactions  Medical  and  Chirurgi- 

cal  Faculty  of  Maryland,  April,  1S81. 

407.  Tiffany  :  Medical  News,  April  16,  1S87. 

408.  Hunt:  American  Journal  of  the  Medical  Sci- 

ences, vol.  lxxxi.,  p.  186. 

409.  Flicker:    Provincial  Medical  Society,  Kings 

Co.,  1879,  vol.  iii. 

410.  Keen  :  Medical  News,  March  26,  1892. 

411.  Basch :     Zeitschrift    fur    Geburtshiilfe    und 

Gyniikologie,  Bd.  xxv.,  H.  2. 

412.  Vickery  :  Boston  Medical  and  Surgical  Jour- 

nal, 1890.  p.  413. 

413.  Gerdes:  Centralblatt  fiir  Gyniikologie,  1890, 

No.  45. 


III.  LABOR, 


[.  THE  PHYSIOLOGY  OF  LABOR* 

Definitions. — Labor  is  the  process  by  which  the  ovum  is  separated  from  the 
maternal  organism  and  extruded  or  extracted.  The  term  normal  labor  (eutocia) 
may  be  restricted  to  labors  with  normal  factors  that  are  terminated  by  the 
natural  forces,  or  it  may  be  narrowed  down  to  include  only  vertex  presenta- 
tions in  anterior  positions  under  right  conditions.  Dystocia,  or  difficult 
labor,  includes  all  forms  of  abnormal  or  complicated  delivery  near  term. 
Premature  labor  refers  to  the  untimely  birth  of  a  fetus  which  has  reached 
the  period  of  viability — that  is,  a  state  of  sufficient  development  to  live 
independently  of  the  mother.  Miscarriage,  or  immature  delivery,  is  usually 
restricted  to  the  expulsion  of  the  fetus  from  the  third  month  until  viability, 
although  it  is  often  used  as  a  synonym  of  abortion,  and  is  the  lay  term  for 
that  mishap,  the  word  "  abortion"  to  the  layman  denoting  criminal  intent. 
The  term  abortion  is  reserved  by  the  obstetrician  for  the  expulsion  of  the 
ovum  in  the  first  three  months. 

Causes  of  Onset  of  Labor. — What  constitutes  maturity  or  ripeness  we  do 
not  know,  and  in  the  indefiniteness  of  our  knowledge  "  we  refer  the  matter  to 
a  law  of  the  organism — a  law  the  cause  of  which  we  do  not  know." 

The  termination  of  pregnancy  is  due  to  some  combination  of  conditions,  no 
one  of  which,  singly,  will  account  for  the  occurrence  of  labor  at  two  hundred 
and  eighty  days  after  the  date  of  appearance  of  the  last  menstrual  period. 
Briefly  stated,  the  chief  factors  are — 

1.  Increasing  irritability,  with  strengthening  intermittent  contractions. 

2.  Changes  in  the  decidua — loosening,  thinning,  and  thrombosis. 

3.  Excess  of  C02  and  lessened  oxygen  in  the  placental  blood  acting  on  the 
motor  centre  for  the  uterus  in  the  medulla. 

4.  Increasing  tension  on  fully-developed  muscular  walls. 

5.  Stronger  fetal  movements  in  more  confined  space. 

6.  Partial  relaxation  of  the  cervix. 

7.  Menstrual  periodicity  (tenth  period). 

8.  Habit  and  heredity. 

9.  Exciting  causes — exercise,  strain,  emotion. 

1.  A  steadily  increasing  irritability  is  probably  the  rule  during  gestation. 
At  certain  menstrual  epochs,  such  as  the  second,  third,  and  seventh,  it  is 
especially  marked,  and  there  is  evident  disturbance  both  of  the  neighboring 
nerves  and  of  uterine  ganglia  in  the  first  and  last  trimesters. 

Intermittent  contractions  occur  regularly  in  the  non-gravid  uterus.     They 

*  The  superior  figures  (')  occurring  throughout  the  text  of  this  section  refer  to  the  bibliog- 
raphy given  on  page  391. 
368 


THE   PHYSIOLOGY   OF  LABOR.  369 

are  distinct  from  the  very  beginning  of  pregnancy,  they  steadily  gain  in 
strength  during  its  progress,  and  at  its  end  rhythmical  hardening  and 
prominence  may  always  be  detected.  The  dividing-line  between  contractions 
and  true  labor-pains  is  not  easily  drawn,  but  as  soon  as  the  ovum  becomes  a 
foreign  body  by  beginning  separation  more  vigorous  action  is  ensured. 

2.  The  changes  in  the  decidua  are  well  epitomized  by  Lusk :'  "  The  re- 
searches of  Friedlander,  Kundrat,  Engelmaun.  and  Leopold  have  demon- 
strated that  the  decidua  vera  of  pregnancy  is  distinguishable  into  an  outer 
dense,  membranous  stratum,  composed  of  large  cells  resembling  pavement  epi- 
thelia,  probably  metamorphosed  cylindrical  cells,  and  an — in  appearance — 
underlying  meshwork,  formed  from  the  walls  of  the  enlarged  decidual  glands. 
It  is  in  this  spongy  layer  that  the  separation  of  the  decidua  takes  place,  the 
fundi  of  the  glands  persisting  even  after  the  expulsion  of  the  ovum.  By  many 
a  fatty  degeneration  of  the  cells  of  the  decidua  has  been  observed  toward  the 
end  of  pregnancy,  but  Leopold,  Dohrn,  and  Langhans  have  shown  that  this  is 
not  of  constant  occurrence.  The  trabecular  which  enclose  the  spaces  of  the 
network  diminish  in  size  with  the  advance  of  pregnancy.  Thus,  while  they 
measure  at  the  fourth  month  about  -^  of  an  inch  in  thickness,  they  become 
gradually  reduced  in  the  subsequent  months  to  2S100  of  an  inch — a  change 
which  materially  facilitates  the  peeling  off  of  the  decidual  surface. 

"  From  the  fourth  month  onward  large-sized  cells  make  their  appearance 
in  the  serotina,  especially  in  the  neighborhood  of  thin-walled  vessels.  The 
largest  of  the  so-called  giant-cells  contain  sometimes  as  many  as  forty  nuclei. 
Though  a  physiological  product,  they  resemble  for  the  most  part  the  so-called 
specific  cancer-cells  of  the  older  writers.  They  are  of  special  obstetrical  inter- 
est from  the  fact,  observed  by  Friedlander  and  confirmed  by  Leopold,2  that 
they  penetrate  the  uterine  sinuses  from  the  eighth  month,  and  lead  to  coagula- 
tion of  the  blood  and  to  the'  formation  of  young  connective  tissue,  by  means 
of  which  a  portion  of  the  venous  sinuses  becomes  obliterated  before  labor 
begins.  The  subtraction  of  these  vessels  from  the  circulation  tends  to  increase 
the  amount  of  the  venous  blood  in  the  intervillous  spaces  of  the  placenta." 

3.  Brown-Sequard  found  by  experiment  that  an  excess  of  C02  circulating 
in  the  blood  of  a  gravid  animal  excited  uterine  contractions,  and  he  claimed 
that  this  excess  of  the  gas  was  the  proximate  cause  of  labor.  His  theory  lacks 
conclusiveness,  however,  because  it  does  not  explain  why  the  CO,  postpones  its 
irritant  action  until  the  end  of  the  ninth  month.  Leopold  believes  that  the 
excess  of  C02  in  the  placental  blood  is  the  result  of  venous  hyperemia  of  the 
placenta,  produced  by  the  spontaneous  thrombosis  in  the  veins  of  the  placental 
site  at  the  end  of  pregnancy,  while  Hasse  credits  it  to  certain  changes  in  the 
circulation  of  the  fetus — chiefly  in  the  crossing  blood-currents  of  the  right 
auricle  and  shrinkage  of  the  ductus  venosus  and  arteriosus.  Spiegelberg 
teaches  that  at  maturity  the  fetus  requires  some  new  substance  not  supplied 
by  the  placenta,  and  that  it  dies  (as  in  extra-uterine  pregnancy)  if  it  does  not 
obtain  it,  while  chemical  substances  no  longer  required  accumulate  in  the 
blood  and  act  as  irritants  to  the  special  nervous  centres. 


370  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

4.  Power  in  1819  called  especial  atteution  to  over-distention  of  the  uterus 
as  a  causative  factor  in  labor  ;  it  can  admirably  be  demonstrated  by  analogy. 
As  the  over-loaded  stomach  or  the  rectum  rejects  its  burden,  so  the  over-dis- 
tended uterus  rebels  and  expels  its  contents  by  the  contractions  of  labor  when 
the  mouth  of  the  organ  begins  to  be  stretched.  The  occurrence  of  premature 
labor  in  hydramnion  and  multiple  pregnancy  sustains  this  theory,  but,  on  the 
other  hand,  it  does  not  account  for  labor-pains  in  extra-uterine  pregnancy. 
The  extensibility  of  the  uterine  wall  has  a  limit,  and  when  this  is  reached  the 
ovum  in  its  growth  presses  more  and  more  upon  the  internal  os.  This  pressure 
excites  a  special  set  of  nerves  and  brings  about  uterine  contractions,  just  as  the 
contact  of  the  drop  of  urine  at  the  neck  of  the  distended  urinary  bladder  ex- 
cites contraction  and  evacuation  of  that  orgau. 

A  theory  of  this  nature  brings  up  the  question  of  the  innervation  of  the 
uterus.  Through  what  set  or  sets  of  nerves  does  the  uterus  receive  its  motor 
impulses  during  labor?  The  nerve-supply  is  largely  from  the  hypogastric  and 
ovarian  plexuses  of  the  sympathetic  system.  The  cervical  ganglion  receives, 
in  addition  to  its  extensive  connections  with  the  sympathetic,  filaments  from  the 
second,  third,  and  fourth  sacral  nerves.  But  Lusk  and  Jacquemart  report 
cases  of  successful  labor  in  patients  suffering  with  paralysis  of  the  lower  ex- 
tremities, retention  of  urine,  and  incontinence  of  feces — a  state  of  affairs  which 
would  lead  one  to  discount  the  importance  of  the  role  played  by  the  filaments 
from  the  sacral  nerves.  Ou  the  other  hand,  the  experiments  of  Schlesinger3 
argue  against  the  exclusive  source  of  motor-supply  resting  with  the  sympa- 
thetic, for  he  was  able  to  elicit  reflex  movements  of  the  uterus  by  stimulation 
after  severing  all  the  branches  of  the  aortic  plexus.  Whether  he  may  not 
have  overlooked  some  of  the  slender  nerve-filaments  in  cutting  the  branches 
of  the  aortic  plexus  is  a  question  worthy  of  consideration,  and  the  possibility 
of  such  an  error  detracts  fronj  the  value  of  his  experiments  and  the  weight  of 
the  conclusions  to  be  drawn  from  tliem.  The  uterine  ganglia  have  a  certain 
independence  of  action,  such  as  the  cardiac  ganglia  possess,  since  rhythmic  con- 
tractions by  both  may  be  kept  up  after  separation.4  Brandt  has  shown  that 
massage  of  no  part  of  the  pelvic  contents  will  produce  contraction  in  the  non- 
gravid  uterus  so  rapidly  as  manipulation  of  the  (supravaginal)  cervix,  and  the 
writer  has  demonstrated  this  for  the  early  weeks  of  pregnancy.5 

Whatever  the  channels  of  nerve-force  may  be,  there  has  been  proved  to  ex- 
ist in  the  medulla  oblongata  a  motor  centre  for  contraction  of  the  uterus  that 
may  be  excited  to  action  by  C02  in  the  blood,  by  anemia,  and  perhaps  by  the 
toxic  substances  retained  in  the  blood  of  one  suffering  from  nephritis.  At  full 
term  something  stimulates  this  centre  to  activity,  with  a  complex,  co-ordinated 
set  of  muscular  contractions  as  the  resultant.  Moreover,  it  is  supposed  by 
Schatz  that  the  uterus  possesses  au  inhibitory  centre  which  is  active  throughout 
pregnancy,  but  which  for  some  reason  ceases  to  act  at  term. 

6.  A  diminished  resistance  in  the  lower  birth-canal  is  to  be  noted.  The 
cervix  is  fully  softened,  the  pelvic  floor  is  edematous  and  relaxed,  and  the 
uterus  and  its  contents  often  sink  low  in  the  pelvis. 


THE  PHYSIOLOGY   OF  LABOR.  371 

7.  The  theory  advanced  by  Tyler  Smith  to  the  effect  that  the  tenth  period 
of  ovarian  excitement  incites  the  nervous  apparatus  of  the  uterus  to  activity  is 
of  some  force,  since  pregnancy  is  often  interrupted  at  menstrual  epochs ;  but 
it  is  open  to  the  same  objection  as  that  just  mentioned,  for  it  does  not  make 
plain  why  the  ninth  or  eleventh  period  fails  to  effect  the  same  result.  More- 
over, single  ovariotomy  has  beeu  performed  many  times,  and  double  ovariotomy 
a  few  times,  during  pregnancy,  without  perceptibly  influencing  its  course. 

8.  Many  multipara?  follow  the  same  rule  in  a  series  of  pregnancies.  In 
other  cases  great  variations  are  seen. 

9.  Finally,  with  all  things  ready,  an  unimportant,  perhaps  accidental, 
occurrence,  such  as  slight  increase  in  intra-abdominal  pressure  from  walking, 
stair-climbing,  coughing,  or  straining  at  stool,  as  well  as  any  mental  irritation 
(anxiety,  care,  anger),  may  be  the  exciting  cause. 

We  have  been  dealing,  then,  with  determining  causes,  factors  in  a  phe- 
nomenon, none  of  which  can  establish  a  claim  to  be  considered  singly  and 
absolutely  causative.  Winckel  sums  up  by  saying  that  labor  is  the  total  of 
several  causes  which  may  enter  into  different  combinations  to  accomplish  the 
same  result.  Lusk  takes  substantially  the  same  ground,  and  Barnes  observes 
that  the  determining  causes  act  synergetically,  not  singly. 

The  fetus  is  mature,  ready  to  undertake  the  complex  acts  of  respiration  and 
digestion  ;  the  imperceptible  uterine  contractions  of  several  weeks  have  loos- 
ened the  attachments  of  the  decidua,  whose  trabecular  have  grown  much  thin- 
ner and  capable  of  easy  rupture ;  the  uterus  by  distention,  perhaps  by  increas- 
ing pressure  of  the  fetus  on  the  internal  os,  has  grown  very  irritable,  the  lusty 
inmate  augmenting  this  condition  by  the  force  and  frequency  of  its  movements. 
The  maternal  blood  contains  an  increased  quantity  of  C02;  venous  thromboses 
in  the  uterine  wall  near  the  serotina  and  in  the  serotina  itself  obstruct  the  cir- 
culation and  cause  stasis  of  the  maternal  blood  returning  from  the  placenta ; 
the  cervix  uteri  becomes  soft  and  dilatable  ;  the  advent  of  the  teuth  menstrual 
date,  with  increased  congestion  and  irritability  of  all  the  generative  organs  as 
a  consequence,  adds  fuel  to  the  pile  ;  the  unknown  factor  deposits  the  spark  at 
the  centre  of  uterine  contraction  in  the  medulla,  and  labor  begins. 

The  Phenomena  of  Normal  Labor. 

The  physiology  of  the  processes  concerned  in  the  expulsion  of  the  fetus 
includes  a  study  of  the  action  of  the  uterine  walls,  the  uterine  ligaments, 
the  abdominal  muscles,  and  the  vagina ;  the  changes  induced  by  labor  in  the 
cervix,  in  the  lower  uterine  segment,  and  in  the  body  of  the  uterus ;  the 
variations  in  the  presenting  pouch  of  membranes;  and  the  character  of  the 
liquor  amnii,  the  formation  of  the  caput  succedaneum,  and  the  changes  in  the 
pelvic  floor.  Then  the  clinical  character  of  the  three  stages  of  labor  will  be 
considered,  leaving  questions  of  mechanism  and  management  for  later  sections. 

Uterine  Contractions. — The  uterine  contractions  of  labor  go  by  the  name 
of  "pains"  in  all  languages,  including  the  speech  of  the  scientist,  because 
of  the  suffering  inseparably  associated  with  them.     The  cause  of  this  suffering 


372  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

is  the  compression  of  the  uterine  nerves  between  the  contracting  muscular 
fibres,  the  tension  of  the  external  os  and  lower  uterine  segment,  the  stretching 
of  the  uterine  ligaments,  and  the  pressure  of  fhe  advancing  fetus  on  the  nerves 
of  the  vagina,  the  vulva,  and  the  neighboring  structures.  Moreover,  hyper- 
emia of  the  lower  end  of  the  spinal  cord  and  its  envelopes  is  probably  in 
part  responsible  for  the  distress. 

The  location  of  the  pain  is,  at  first,  in  the  lumbo-sacral  region,  and  later 
in  the  abdomen  or  down  the  thighs.  The  most  severe  degree  of  pain  is  felt 
at  the  vulva  as  the  head  passes.  The  onset  of  the  contraction  is  more  rapid 
than  the  decline.  The  pain  begins  suddenly  a  few  seconds  after  the  beginning 
of  the  contraction — as  may  be  seen  by  the  bulging  forward  of  the  fundus  or 
as  felt  by  the  examining  hand — reaches  and  retains  for  a  few  seconds  its  acme 
of  intensity,  and  then  gradually  subsides.  If  each  pain  be  divided  into 
periods  of  increase,  acme,  and  decrease,  the  acme  will  occupy  the  greatest 
length  of  time  of  the  three  divisions,  the  total  duration  of  a  pain  being  about 
oue  minute.  The  suffering  is  commonly  more  severe  in  very  young  or  in 
elderly  primiparse  than  in  those  in  the  prime  of  physical  life.  Susceptibility 
to  pain,  and  general  vigor,  have  much  to  do  with  the  amount  of  anguish 
experienced,  it  being  among  serene  women  and  dull-witted  and  sturdy-limbed 
hospital  patients  that  we  oftenest  see  quiet  labors.  Painless  deliveries  have 
been  reported,  but  they  are  rare. 

The  muscular  fibre  of  the  uterus  is  non-striated,  and  the  contractions,  as  in 
all  organs  of  like  histological  structure,  are  peristaltic,  involuntary,  and  inter- 
mittent. Contractions  sweep  over  the  uterus  in  a  peristaltic  wave,  probably 
travelling  from  the  opening  of  the  Fallopian  tubes  down  to  the  cervix,  reaching 
a  swift  acme,  and  subsiding  within  twenty  or  thirty  seconds.  Waves  in  both 
directions  have  been  observed  in  the  uteri  of  some  of  the  lower  animals. 
Though  mainly  controlled  by,the  sympathetic  system  of  nerves,  and  hence  inde- 
pendent of  the  will,  the  pains  are  nevertheless  influenced  to  some  extent  bv  the 
brain — a  fact  demonstrated  by  the  effect  of  fright  or  of  excitement  in  retarding 
or  even  in  stopping  labor.  The  pains  last  from  thirty  to  ninety  seconds,  and 
the  peristaltic  action  from  twenty  to  thirty  seconds  ;  the  interval  is  about  thirty 
minutes  at  first,  whereas  at  the  end  of  labor  it  is  but  two  to  three  minutes,  and 
nearly  disappears  as  the  head  emerges.  Symmetrical  pains  often  occur  in 
groups,  followed  by  shorter  or  almost  abortive  pains.  As  to  the  force  exerted, 
the  pressure  during  the  height  of  a  pain  never  exceeds  100  millimeters  (4 
inches)  of  mercury,  the  average  being  60  millimeters  (2§  inches ;  Schatz). 
Leaman  measured  the  force  with  which  the  head  advanced  (not  the  force  with 
which  it  was  propelled),  and  found  a  high  pressure  to  be  five  pounds.  Forceps 
was  required  where  it  did  not  exceed  two  and  a  half  pounds.6  The  force  of 
the  pain  remains  about  the  same  during  the  entire  labor,  or  it  may  increase  by 
a  fourth,  and  this  with  no  regard  to  weariness  on  the  part  of  the  patient.  The 
force  does  not  increase  with  the  resistance  offered,  but  the  pains  simply  become 
more  frequent  and  last  longer.  The  type  of  the  pains  is  nearly  constant  in  the 
same  patient  (Schatz). 


THE   PHYSIOLOGY   OF  LABOR. 


\  V 


Fig.  169.— Palpation  of  the  cervix  before  la- 
bor. The  two  rings  are  shown,  with  the  finger-tip 
touching  what  may  be  called  clinically  the  "  in- 
ternal os  "  (one-half  natural  size). 


The  amount  of  force  exerted  by  the  pains  is  supposed  to  range  between  seven- 
teen and  eighty  pounds.  Our  methods  of  measuring,  however,  are  defective, 
Duncan  and  Poppel,  who  studied  the 
force  required  to  rupture  the  mem- 
branes, found  that  in  easy  cases  it  was 
hardly  more  than  the  weight  of  the 
child,  and  only  in  severe  cases  did  it 
rise  to  fifty  pounds.  Schatz7  passed  a 
rubber  bag  into  the  uterus  during  labor 
and  connected  it  with  a  gauge,  register- 
ing fifty-five  pounds  as  the  maximum. 
An  obstetrician  knows  that  all  the  mus- 
cular power  he  possesses  is  sometimes 
insufficient  to  prevent  rapid  expulsion 
of  the  head. 

The  changes  in  shape  in  the  uterus 
during  contraction  are  marked.  In  the 
quiescent  state  it  rests  against  the  spinal 
column,  ovoid  in  shape,  the  transverse 
exceeding  the  antero-posterior  diameter. 
During  contraction  these  diameters  be- 
come about  equal,  the  uterus  assumes  an  ovoid  or  somewhat  cylindrical  form, 
and  by  means  of  this  increase  of  the  antero-posterior  diameter  and  the  con- 
tractile action  of  the  broad  and  round 
ligaments  the  fundus  is  forced  forward 
against  the  abdominal  wall.  At  the 
same  time  the  uterus  becomes  longer  at 
the  expense  of  the  lower  uterine  seg- 
ment and  the  cervix  (Fig.  239,  p.  475). 
Action  of  the  Ligaments. — The 
uterine  ligaments — the  round  ligaments, 
the  lower  part  of  the  broad  ligaments, 
and  the  utero-sacral  bands  —  contain 
much  muscular  tissue  which  is  directly 
continuous  with  that  of  the  uterine 
wall.  Contraction  of  this  muscular 
tissue  occurs  with  each  pain,  and  serves 
to  fix  or  to  steady  the  uterus  in  position 
at  the  brim,  and  to  assist  in  lifting  and 
holding  it  at  an  angle  favorable  for  expulsion  of  the  fetus  (Fig.  214,  p.  438). 
Action  of  the  Abdominal  Muscles. — Xext  to  the  uterine  contractions 
the  force  of  the  abdominal  muscles  is  the  important  expulsive  agent.  "We 
include  all  those  muscles  that  fix  the  thorax  and  pelvis  or  narrow  the  abdom- 
inal cavity.  The  mechanical  problems  involved  are  omitted  here,  as  they 
are  discussed  in  the  section  on  Mechanism  of  Labor,  page  438.     The  action 


l>\\-i 'lining  diiattitii 
of  internal  os. 


Further  dilatation 
of  internal  os. 


Complete  effacement 
of  internal  os,  zvitk 
sharp  external  os. 


Fig.  170.— Diagram  showing  the  sensation  to 
the  examining  finger  of  widening  and  efface- 
ment of  the  internal  os  during  dilatation  of  the 
cervix,  and  the  knife-like  edge  of  the  external 
os  (one-half  natural  size). 


374 


AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 


Fig.  171.— Section  of  cervix  at  term  (Wal- 
deyer).  The  irregular  blotted  black  marks  with- 
in the  cervical  canal,  running  to  the  membranes, 
denote  mucous  membrane  of  cervix  ;  the  de- 
cidua  runs  in  a  wavy  line  beneath  the  mem- 
branes. 


on  the  part  of  the  woman  is  voluntary  at  first,  but  becomes  less  so  as  labor 

advances,  as  shown  by  her  inability  to  withhold  strong  pressure  at  the  time 

when  the  pelvic  floor  is  endangered. 
Such  assistance  to  the  uterus  is  not 
absolutely  necessary,  for  labor  may 
be  accomplished  in  the  absence  of 
the  action  of  these  external  forces, 
as  in  paralysis ;  but  when  the  head 
lies  in  the  pocket  formed  by  the 
curve  of  the  sacrum  and  the  partly 
stretched  pelvic  floor,  having  to 
turn  nearly  a  right  angle  in  its 
course,  the  power  brought  to  bear 
by  the  abdominal  muscles  is  of 
very  great  moment.  From  the 
atrophy  of  the  trunk-muscles  due 

to  corset-wearing,  failure  of  force  at  this  crisis  often  calls  for  forceps  extraction. 
The  uterus  is  raised  by  the  round  ligaments  so  that  abdominal  pressure  acts 

to  better  advantage.     The  uterus  is  compressed  from  all  sides,  is  supported  by 

the  pelvic  walls,  and  is  arrested  in  attempts  to  slip  downward  by  the  utero- 

sacral  and  broad  ligaments  and  the 

sacral  curve,  while  its  contents  are 

pressed  out.    The  increased  tension 

on   all  the  contents  of  the  trunk 

sends  blood  to  the  extremities  and 

flushes  the  face  of  the  patient.    Be- 
low the  pelvic  brim  the  tension  is 

not  brought  to  bear,  and  conges- 
tion produces  edema  and  softening 

of  the  cervix  and  pelvic  floor.     At 

times  the  child   is   expelled   with 

considerable  force  by  means  of  this 

added  power,  and  the  uterus  may 

even  be  inverted  by  these  efforts 
Action  of  the  Vagina. 

advancing   head.     When, 


Fig.  172.— Cervix  of  multipara  at  beginning 
of  labor;  the  internal  os  is  at  the  edge  of  the 
crater  (froEen  section,  Winter). 


f  the  external  muscular  structures. 
— At  first  the  vagina  opposes  some  obstacle  to  the 
lowever,  a  large  circumference  has  passed,  any 
onward  motion  may  receive  slight  aid  from  contractions  of  the  vagina.  Figure 
188  (p.  387)  shows  how  the  vaginal  walls  are  smoothly  fitted  to  the  child  even 
after  the  exit  of  the  head  has  greatly  distended  the  passage. 

Changes  in  the  Cervix  during-  Labor. — Although  palpation  of  the  exter- 
nal surface  of  the  cervix  may  give  the  impression  of  a  smooth  expanse  of 
stretched  rubber  around  the  opening,  yet  when  the  finger  is  passed  within  the 
cervical  canal  as  far  as  the  membranes,  is  hooked  forward,  and  then  slowly 
withdrawn,  one  detects  two  well-defined  rings  with  a  1-  to  2-inch  (3.5-  to  5- 
centimeter)  passage  between  them,  and  finds  that  this  passage  has  yielding  side 


THE   PHYSIOLOGY   OF   LABOR. 


375 


Rectum. 


Fig.  173.— Cervix  of  five  and  a  half  months'  primipara  in 
dilatation  period,  with  marked  irregularity  in  progress  of 
dilatation  of  posterior  and  anterior  lips,  the  posterior  being 
nearly  flattened  (Winter  ;  frozen  section,  five-eighths  natural 
size).    Compare  widening  funnel  or  crater  with  Figure  169. 


walls  (Figs.  169,  170,  177).  Whether  this  inner  ring  be  the  true  internal  os, 
or  only  the  upper  limit  of  the  vaginal  portion  of  the  cervix,  we  may  be  allowed 
to  call  it,  for  clinical  pur- 
poses, the  internal  os,  since 
we  desire  to  study  its  be- 
havior during  the  dilatation 
stage. 

At  the  beginning  of 
labor  in  the  primipara  the 
cervix  is  barely  passable  by 
the  finger-tip.  Dilatation 
of  the  internal  os  occurs 
first,  and  it  may  open  rather 
widely  before  the  external 
os  begins  to  gape  (Fig.  170). 
In  this  case  the  cervix  thins 
out  to  a  flat  ring  over  the 
watch-glass  membranes,  and 
the  external  os  may  form  a 
sharp,  parchment-like  edge 
as  the  internal  os  merges  with  the  lower  uterine  segment  and  the  membranes 
or  the  presenting  part  is  applied  directly  to  the  external  os.  At  other  times 
the  two  rings  draw  back  in  less  marked  succession  (Figs.  172,  173).  In  mul- 
tipara, the  more  open  canal 
freely  admits  the  finger  dur- 
ing the  last  month,  and  the 
condition  is  suggestive  of 
labor  begun.  But  an  inner 
edge  may  always  be  distin- 
guished (Fig.  173)  until  the 
early  labor-pains s  or  the 
threatening  preliminary 
pains  begin.  The  effect  of 
such  early  pains  in  com- 
mencing the  dilatation  of 
the  cervix  in  certain  cases  is 
shown  in  Figure  178.  In  multipara?  labor  is  likely  to  pull  back  the  whole 
cervix  bodily,  but  with  some  thinning  and  with  a  somewhat  irregular  edge. 
Gradually  the  circle  widens  until  it  merges  imperceptibly  into  the  uterine  wall, 
leaving,  as  a  rule,  to  represent  the  external  os,  a  slightly  raised  encircling  ring 
on  the  wall  of  the  curved  birth-tube  3  millimeters  (-^  inch)  in  thickness,  located 
against  the  back  of  the  symphysis  in  front  and  halfway  up  the  sacrum  behind 
(Figs.  134, 188).  The  wall  of  the  cervix  is  then  2  millimeters  (-g3^- inch)  in  thick- 
ness, and  the  cervix  is  said  to  be  effaced.  The  anterior  lip  may  be  nipped 
between  the  bony  ring  (pelvis)  and  the  ball  of  bone  (fetal  head)  and  become 


Fig.  174.— Dilating  cervix  of  eight  months'  primipara,  with 
pronounced  thinning  of  posterior  lip  (Winter :  frozen  section, 
two-thirds  natural  size). 


376 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


elongated  and  edematous,  even  to  the  extent  of  appearing  at  the  vulva  dur- 
ing delivery  or  of  hanging  without  it  afterward.  In  patients  with  contracted 
inlets  the  external  os  often  remains  at  or  near  the  brim  after  full  dilatation. 
The  dilatation  is  estimated  either  by  guessing  at  the  coin  which  it  seems  to 
resemble  in  size,  or  by  stating  the  inches  of  its  diameter,  or  the  number  of 
fingers  which  the  elastic  ring  will  admit.  Although  the  cervix  may  not  be 
found  greatly  dilated,  it  may  be  dilatable  to  a  large  size,  as  determined  by 
the  introduction  of  four  fingers  or  the  whole  hand.     The  common  error  of  the 


Fig.  175.— Cervix  compressed  between  the  bead  and  the  pelvic  floor,  at  the  beginning  of  labor  in  a 
Vl-para  (Barbour,  one-third  natural  size).  The  cervix  extends  from  the  tuberosity  up  to  the  right-hand 
a;  the  vagina  is  shown,  and  also  the  ureter  and  the  base  of  the  broad  ligament;  the  area  on  the  side  not 
covered  with  peritoneum  being  the  shaded  space  (a,  a,  a). 

beginner  is  to  believe  that  the  cervix  is  much  more  widely  opened  than  it  is  in 
fact.  He  is  sometimes  deceived  into  thinking  the  cervix  has  gone  by  the  exceed- 
ing thinness  of  the  tissue  stretched  taut  over  the  head  (Figs.  173,  216  ;  p.  435), 
or,  again,  by  the  softness  of  the  yielding  edges.  The  cervix  may  remain  in 
a  stationary  and  partly  dilated  condition  for  hours,  or,  in  rare  cases,  for  days. 
It  may  close  after  partial  dilatation — even  from  the  size  of  three  fingers. 

The  mechanical,  factors  effecting  dilatation  are  discussed  on  pages  474-480. 
The  active  agents  are  :  (1)  Contraction  of  the  longitudinal  fibres  of  the  uterine 


THE  PHYSIOLOGY   OF  LABOR.  377 

body,  pulling  the  cervix  up  over  the  ovum ;  (2)  hydrostatic  pressure  of  the 
bag  of  waters ;  (3)  wedge-action  of  the  presenting  part ;  (4)  softening  of  the 
cervix. 

During  a  contraction  there  is  high  tension  in  all  the  uterine  blood-ves- 
sels; the  unsupported  vessels — those  of  the  cervix — become  engorged,  and  the 
lymphatic  interspaces  are  infiltrated  with  serum  and  loosened;  thereby  the 
force  of  cohesion  is  lessened.  Were  it  not  so,  the  elastic  cervix  would  close 
down  on  the  shoulders  after  the  passage  of  the  head.  "  Indeed,  the  conditions 
of  an  elastic  tube  are  not  infrequently  realized  in  versions  where  an  attempt  is 
made  to  extract  the  fetus  through  an  imperfectly  dilated  os;  in  which  case, 
after  the  disengagement  of  the  shoulders,  the  cervix  is  apt  to  close  upon  the 
neck  and  arrest  the  delivery  of  the  after-coming  head.  That  this  complication 
does  not  happen  as  a  rule  is  due  to  the  fact  that  in  natural  labors  the  mechan- 
ical expansion  is  associated  with  certain  organic  changes  which  render  the  cer- 
vix soft  and  distensible,  and  which  at  the  same  time  diminish  its  retractility."9 

To  bring  the  cervix  to  a  circle  of  a  diameter  of  5  centimeters  (2  inches) 
frequently  demands  two-thirds  of  the  total  time  required  for  full  dilatation. 
Irregular  dilatation  is  not  infrequent,  wherein  the  posterior  lip  is  further 
effaced  than  the  anterior,  or  inversely,  but  the  former  is  more  common.  From 
the  frozen  sections,  the  first  process  would  seem  to  be  constant  in  occurrence 
and  most  marked  in  character  (Fig.  173). 

Location  of  the  Orifice. — The  internal  os  is  found  at  the  beginning  of  labor 
and  in  frozen  sections  6.3  centimeters  (2^  inches)  below  the  brim,  being  a  little 
lower  than  in  the  nullipara.10  The  cervix  may  point  backward,  and,  when 
there  is  much  difficulty  in  reaching  it  far  up  toward  the  promontory,  one 
may  be  obliged  to  hook  the  anterior  lip  downward  with  the  finger  in  suc- 
cessive sections  until  the  external  os  can  be  caught  (Fig.  64,  p.  81,  Vol.  II.). 
A  cervix  by  excessive  distance  from  the  vulva  may  inform  ns  of  false  labor- 
pains,  point  to  a  contracted  pelvis  or  to  an  abnormal  presentation.  The 
cervix  may  be  found  with  the  head  packed  into  it,  pressing  it  downward 
against  the  pelvic  floor  and  toward  the  vulvar  opening  (Fig.  175). 

Changes  in  the  Lower  Uterine  Segment. — The  two  beliefs  concerning 
this  portion  of  the  uterus  can  only  be  summarized.  Schroeder  and  his  school 
teach  that  the  lower  uterine  segment  is  that  part  of  the  wall  of  the  body  of  the 
uterus  (Fig.  176)  extending  from  the  contraction-ring  above — the  level  at  which 
the  peritoneum  is  found  firmly  adherent — to  the  internal  os  below;  that  it  is 
constituted  of  more  loosely  adherent  muscular  layers  than  the  wall  higher  up ; 
and  that  it  is  relatively  passive  during  labor.  By  its  anatomical  structure  and 
by  the  epithelial  covering  of  its  mucous  membrane  the  lower  uterine  segment 
is  differentiated  from  the  cervix  in  both  the  pregnant  and  the  puerperal  uterus. 
In  pregnancy  the  internal  os  may  be  found  by  its  forming  the  upper  end  of 
the  closed  cervical  canal.  With  this  point  the  denser  structure,  with  its  con- 
nective-tissue appearance,  the  character  of  mucous  membrane  and  its  junction 
with  the  decidua  above,  and  the  upper  limit  of  the  arbor  vitas,  usually  coincide. 
The  lower  segment  differs  distinctly  from   the   upper,  to  which   it   belongs 


378  AMERICAN    TEXT-BOOK   OF   OBSTETRICS. 

anatomically,  in  possessing  loosely  connected  muscular  layers  which  are  easily 
separated,  whereas  the  rest  of  the  body  of  the  uterus  is  made  up  of  inseparably 
interlaced  bundles  which  can  only  be  dissected  from  one  another,  even  in  the 
thinnest  layers,  by  destroying  the  structure  (Hofmeier).11  "  The  physiological 
behavior  of  the  lower  uterine  segment  during  labor  is  essentially  passive,  as 
opposed  to  the  remaining  portion  of  the  uterus,  which  is  sharply  contrasted 
with  it  by  contractions."  The  difference  between  the  two  is  palpable,  after 
vigorous  uterine  contractions,  to  the  hand  within  the  cavity,  the  ring  being 
occasionally  detected  by  the  hand  without  as  well.  The  term  "  contraction- 
ring,"  though  firmly  seated,  should  yield,  in  the  writer's  opinion,  to  the 
more  correct  "  retraction-ring,"  which  is  self-explanatory.  The  cervix  aver- 
ages 4  cm.  (1 1  inches)  from  external  to  internal  os,  and  the  retraction-ring 
stands  about  6  cm.  (21  inches)  above  the  internal  os. 

The  writer  has  given  precedence  to  the  views  of  those  investigators  who 
believe  that  the  cervix  remains  unchanged  until  the  beginning  of  labor.     Only 

Taylor, 
Muller, 
Sehroeder, 
Hofmeier, 
Waldeyer, 
et  al. 


LOWER 

UTERINE 

SEGMENT. 


CERVIX 

(synonymous 
lower  uierin 
ment). 


Fig.  170.— Diagram  illustrating  the  two  teachings  anent  the  lower  uterine  segment  and  the  cervix. 
On  the  left  side  an  internal  os  has  been  added  for  the  sake  of  clearness,  although  in  the  frozen  sections 
of  women  with  full  dilatation  it  is  rarely  apparent  macroscopically  (one-third  natural  size). 


the  briefest  outline,  however,  of  the  voluminous  controversy  12  can  be  given, 
and  the  opposite  side  stated.  The  older  theory  held  that  toward  the  end  of 
pregnancy  the  upper  portion  of  the  cervix  was  expanded  and  drawn  up  to 
form  part  of  the  general  uterine  cavity,  leaving  only  the  small  vaginal  por- 
tion of  the  cervix  below.  Braun,  whose  section  is  given  in  Figure  134, 
believes  that  the  semicircular  ledge  with  the  large  vein  (Kranzvene)  is  the  in- 
ternal os,  10  to  11  centimeters  (4  inches)  above  the  external  os;  Bandl  confirms 
this.  He  now  believes,13  with  Kustner,  that  in  first  labors  the  mucous  mem- 
brane of  the  dilated  portion  of  the  cervix — the  lower  uterine  segment — becomes 
torn  or  stripped  off',  and  subsequently  there  is  formed  upon  the  denuded  surface 


THE   PHYSIOLOGY    OF  LABOR. 


379 


Closely 
interwoven 
layers. 


a  new  membrane  not  distinguishable  from  that  of  the  corpus,  which  in  future 
pregnancies  is  capable  of  forming  a  decidua.  Bayer14  concludes  that  "the  ex- 
cessively thin  decidua  of  the  lower  uterine  segment  passes  into  cervical  mucous 
membrane  on  the  posterior  wall  of  that  segment,  and  that  the  lower  uterine 
segment  and  suftravaginal  cervix  are 
one  and  the  same  thing.  It  envelops 
the  presenting  part  during  labor,  it  is 
thinned  out,  distended,  paralyzed,  while 
the  thick,  contractile  muscle-mass  of  the 
corpus  lies  above,  where  the  phenomena 
of  contraction  occur  with  their  expul- 
sive effect  upon  the  uterine  contents." 

Practically,  the  lower  uterine  seg- 
ment interests  us  as  the  common  seat 
of  rupture  of  the  uterus.  During  long 
labors,  or  where  obstruction  is  asso- 
ciated with   vigorous  contractions,  ex- 


Retraction-ring. 


treme  thinning  occurs  at  this  level,  and 
in  such  cases  the  retraction-ring  can 
sometimes  be  felt  as  a  band  or  ridge  in 
the  vicinity  of  the  navel  to  serve  as  a 
danger-signal. 

The  thickness  of  the  lower  uterine 
segment  was  measured  by  the  writer  on 
such  of  the  frozen  sections  as  would  ad- 
mit of  study.  In  5  cases  at  the  eighth 
and  ninth  months  of  pregnancy  the 
average  thickness  of  the  wall  was  6  mil- 
limeters Q-  inch),  the  extremes  being  5 
and  10  millimeters  (^  to  ^  inch).  In 
5  cases  in  the  stage  of  dilatation  the 
average  thickness  was  3.6  millimeters 
(■^  inch),  the  extremes  being  2  and  5 
millimeters  ( -^  to  T3g-  inch).  In  6  cases 
in  the  expulsion  stage  the  average  thickness  was  3.5  millimeters  (^  inch),  the 
extremes  being  2  and  7  millimeters  (yg-  and  -^  inch  plus).  The  remarkable 
thing  in  this  series  is  that  there  are  so  many  instances  where  a  measurement 
close  to  2  mi  I  i  meters  (Jg-  inch)  was  found,  in  some  sections  of  the  wall,  either 
in  the  first  or  the  second  stage — namely,  in  seven  different  patients.  Thus  we 
may  say  that  be/ore  labor  the  wall  of  the  lower  uterine  segment  is  6  millimeters 
(^  inch)  thick,  and  during  labor  3.5  millimeters  (\  inch).  Anterior  and  poste- 
rior walls  are  rarely  equal  in  thickness,  but  the  sections  are  nearly  equally 
divided  on  thinner  anterior  or  thinner  posterior  walls. 

Changes  in  the  Body  of  the  Uterus. — Thickening  of  the  wall  of  the 
upper  uterine  segment  is  a  somewhat  constant  factor.     It  is  especially  marked 


Fig.  177.— Section  of  the  wall  of  the  pregnant 
uterus  (Hofmeier).  The  difference  in  texture  be- 
tween cervix  and  lower  uterine  segment,  accord- 
ing to  Hofmeier,  is  clearly  shown,  as  well  as  the 
loose-meshed  and  close-meshed  muscle-layers  of 
the  upper  and  lower  uterine  segments. 


380 


AMERICAN    TEXT- BOOK    OF    OBSTETRICS. 


in  long  or  obstructed  labors  (Figs.  134, 191,  291).  The  average  thickness  of 
the  uterine  wall  at  term  is  the  same  as  during  the  early  dilatation  stage,  as 
measured  on  eight  frozen  sections — namely,  7  millimeters  (\  inch).     Toward 


Fig.  178.— Demonstration  of  retraction-ring  (Hofmeier).  A  multipara  who  has  been  in  vigorous  labor 
several  hours,  is  found  with  the  head  well  above  the  inlet ;  A,  on  examining  between  pains,  the  finger 
finds  no  upper  limit  to  the  cervix,  but,  following  along  the  inner  aspect  of  the  relaxed  anterior  wall  of 
the  uterus  to  two  or  three  fingers'  breadth  above  the  upper  border  of  the  symphysis,  it  encounters  the  prom- 
inence of  a  ring  of  feeble  tension  ;  B,  when  a  contraction  starts,  the  ring  becomes  more  prominent  and 
tense.  It  is  only  after  the  bag  of  forewaters  becomes  tense  in  its  turn  that  the  portion  of  uterine  wall 
below  the  ring  (the  lower  uterine  segment)  loses  its  flabbiuess  and  that  one  is  conscious  of  the  formation 
of  a  second  ring,  the  internal  os,  about  4  cm.  (1*4  inches)  above  the  external  os. 

the  close  of  the  expulsion  stage  it  is,  on  five  sections,  from  9  to  18  millime- 
ters (|  to  |  inch),  averaging  1  centimeter  (-§  inch). 


Fig.  179.— Form  of  membranes  during  dilata- 
tion, watch-glass  (Varnier) :  the  presenting  part  is 
large  and  fills  the  cervix  (one-sixth  natural  size). 


Fig.  180.— Form  of  membranes  with  less  effi- 
cient filling  of  cervix  and  pelvis,  and  larger  quan- 
tity of  fore-w-aters  (modified  from  Varnier). 


Bag  of  "Waters — Forewaters. — Through  the  dilating  cervix  the  fetal 
envelopes  are  felt,  growing  tense  during  the  pains  or  just  before  the  sensation 
of  suffering  comes.     The  ovum  is  being  peeled  off  the  lower  uterine  segment 


THE   PHYSIOLOGY    OF   LABOR. 


381 


and  protruded.  We  note  the  amount  of  tension,  the  shape  of  the  protrud- 
ing sac,  and  its  volume,  and,  later,  the  location  of  the  tear.  The  tension  is 
usually  intermittent,  as  above  stated.  At  times  we  detect  a  permanent 
tension  and  look  out  for  hydramnion  or  twins. 

The  shape  of  the  sac  depends  on  the  shape  or  size  of  the  presenting  part, 
the  elasticity  of  the  membranes,  and  the  amount  of  liquor  amnii.  It  may 
be  (1)  Flat ;  (2)  watch-glass — this  is  usual  with  vertex  presentations  (Fig. 
179) ;  (3)  hemispherical — it  may  bulge  full  and  round  (Fig.  1 80)  ;  (4)  glove- 
finger — it  may  be  elongated  in  shape  when  the  cervix  is  narrow  and  the  pre- 
senting part  does  not  fill  it,  as  in  knee  or  shoulder  presentations  (Fig.  181); 


Fig.  181.— Glove-finger  form  where  the  presenting 
part  is  small  (modified  from  Varnier). 


Fig.  182. — Fear-shaped  pouch  seen  with  some  cases 
of  macerated  fetus  (modified  from  Varnier). 


(5)  pear-shaped  (Fig.  1 82),  as  where   the   fetus  is  dead   and   macerated ; 15 

(6)  double,  as  with  twins — but  very  rarely. 

The  membranes  are  slightly  permeable  under  pressure  (Pinard),  and  at 
times  the  amnion  will  leak  into  the  chorion,  giving  a  double  pouch.  The 
amnion  is  most  elastic,  and,  if  the  chorion  is  torn,  may  stretch  to  the 
vulva. 

The  cervix  and  lower  uterine  segment  are  pushed  sidewise  by  the  elastic 
bag.  The  chorion  often  separates  from  the  decidua.  The  attachment  of 
the  membranes  until  the  beginning  of  labor  runs  down  to  the  internal  os ; 
during  dilatation  to  the  retraction-ring.  In  normal  cases16  the  coverings  of 
fetal  origin  are  not  separated,  maternal  and  fetal  membranes  parting  at  the 
level  of  the  lower  pole.  In  certain  cases  before  rupture  the  chorion  and 
amnion  may  already  be  separated  throughout  or  far  up  on  the  cord. 

Normally  the  membranes  give  way  on  full  dilatation  of  the  cervix  when 
pressing  on  the  pelvic  floor.  At  times  rupture  occurs  days  or  hours  before 
labor,  from  low  implantation  of  the  placenta.17  In  Poullet's  case  the  mem- 
branes gave  way  six  days,  and  in  that  of  Matthews  Duncan  forty-five  days, 
before  labor.  A  copious  discharge  of  fluid  that  has  collected  between  the 
ovum  and  the  uterus  and  due  to  a  catarrhal  endometritis,  called  "  hydrorrhcea 
gravidarum,"  may  deceive  one  into  believing  that  the  amniotic  sac  is  emptv. 


382 


AMERICAN    TEXT- BO  OK    OF    OBSTETRICS. 


A  more  common  cause  of  error  is  the  gushing  of  odorless  hysterical  urine. 
At  times  rupture  is  delayed  until  the  membranes  bulge  through  the  vulva. 
In  rare  instances  the  child  is  born  enveloped  completely  in  the  unbroken 
sac  ;  this  is  the  "  caul." 

The  chorion  usually  gives  way  first,  having  a  firmer  attachment,  as  the 
amnion  can  loosen  over  most  of  its  surface  and  slip  downward  and  out.  The 
seat  of  rupture  may  not  correspond  with  the  opening  of  the  cervix.  If  it  is 
on  the  side  wall,  the  waters  may  leak  more  slowly,  but  this  slow  flow  of  the 
fore-waters  is  not  very  often  seen,  although  discharge  of  the  hind-waters  in 
jets,  as  the  presenting  part  recedes  from  its  tight  fit  in  the  cervix  during  a 
contraction,  may  simulate  it.  Frequent  gushes  of  so-called  "  liquor  amnii  " 
are  often  only  urine.  After  rupture  the  waters  may  come  away  with  a  forcible 
gush  or  may  leak  slowly.      On  examination  after  delivery  the  position  of 


JpLACENm- 


V  <\ 


2^ 


■ffmRANtr- 


Fig.  ISo.— Placenta  and  membranes  after  delivery,  to  show  how  the  relation  of  the  opening  to  the 
placenta  indicates  the  site  of  the  latter:  I.,  lateral  implantation  ;  II.,  fundal  implantation;  III.,  placenta 
previa  marginalis. 


the  tear  in  the  membranes  shows  the  location  of  the  placenta  in  the  uterus 
(Fig.  183).  An  opening  opposite  the  after-birth  would  denote  implantation 
in  the  fundus  ;  a  tear  close  to  the  margin  of  the  placenta  would  indicate  pla- 
centa prsevia  ;  and  one  of  the  intermediate  degrees  is  also  shown. 

Character  of  the  Liquor  Amnii. — Ordinarily  the  waters  have  a  slightly 
turbid,  yellowish  color.  At  times  the  amniotic  fluid  is  thick  with  greenish  or 
brownish  meconium,  due,  perhaps,  to  undue  pressure  on  the  child,  and  some- 
times indicative  of  danger,  except  in  breech  presentations.  Flakes  of  skin 
and  a  muddy  consistency  suggest  a  macerated  fetus.  Bright  blood  in  any 
quantity  within  the  membranes  indicates  premature  separation  of  the  placenta 
with  leakage  into  the  amniotic  sac,  but  is  very  rare. 

Formation  of  the  Caput  Succedaneum. — The  caput  succedaneum  is  an 
edematous  swelling  that  develops  on  the  presenting  part  of  the  child  as  the 
cervix  expands.  The  cervix  makes  pressure  all  over  the  presenting  part  dur- 
ing uterine  contractions,  except  at  one  spot,  and  here  serous  infiltration  develops 
a  dough}'  prominence.     The  size  of  this  swelling  varies  with  the  duration  of 


THE   PHYSIOLOGY    OF  LABOR. 


383 


the  labor.  If  it  occurs  on  the  face,  the  grotesque  disfigurement  alarms  the 
family,  but  the  swelling  subsides  in  a  day.  The  scrotum  may  assume  large 
dimensions  in  breech  labors.  On  the  scalp  the  position  of  the  edema  serves  to 
indicate  the  position  in  which  the  head  enters  the  pelvis,  provided  too  long 
delay  in  the  lower  birth-canal  has  not  occurred.  The  tumor  is  located  on  that 
end  of  the  head  and  that  side  of  the  head  opposite  in  name  to  the  position. 


Fig.  184.— Location  of  the  caput  suceedaneurn,  and  its  indication  of  the  original  position  of  a  vertex 

presentation. 

Thus  in  the  left  occipito-anterior  position  it  is  found  to  the  right  posteriorly  ; 
in  right  occipito-posterior,  to  the  left  and  front  (Fig.  184). 

Clinical,  Course  of  Labor. 
Signs  of  Beginning  Labor. — From  eight  to  fourteen  days  before  labor 
"  sinking"  or  "  lightening"  occurs  in  a  considerable  number  of  patients.  The 
uterus  drops  lower,  the  fundus  falls  forward,  the  head  engages  or  descends  to 
lie  on  the  pelvic  floor  (Fig.  175).  and  as  a  consequence  the  patient  experiences 
a  sense  of  relief,  breathes  more  freely,  digests  better,  and  has  looser  waistbands. 
This  may  never  occur  in  a  given  patient,  or  it  may  happen  two  days  or  four 
weeks  before  delivery.  In  half  the  primigravidas  Bruhl  examined  he  found 
the  greatest  circumference  of  the  head  beneath  the  brim  at  the  end  of  preg- 
nancy where  the  inlet  was  roomy,  whereas  in  only  one-third  of  the  multi- 
gravidse  was  this  condition  seen,  owing  to  the  laxer  state  of  the  abdominal 
wall  after  first  pregnancies.  On  the  other  hand,  irritability  of  the  bladder 
and  venous  obstruction  in  the  legs  or  the  labia,  with  more  difficulty  in  walk- 
ing, may  result  from  the  intrapelvic  pressure.  At  the  time  of  subsidence  the 
intermittent  contractions  may  begin  to  be  painful,  so  that  labor  is  supposed  to 


384 


AMERICAS    TEXT-BOOK    OF    OBSTETRICS. 


be  under  way,  the  pains  often  being  grouped  in  certain  parts  of  the  day  or 
night,  and  being  most  commonly  seen  among  multipara?.  Late  in  pregnancy 
the  vagina  and  the  vulva  are  relaxed,  a  glairy  mucus  lubricating  them  and 
facilitating  internal  pelvic  measurement  and  examination. 

The  only  certain  method  of  determining  whether  labor  is  under  way  is  by 
digital  exploration  of  the  cervix.  By  passing  the  finger  within  the  cervix  and 
hooking  it  forward  we  may  determine  whether  the  internal  os  is  widening  or 
disappearing  (Fig.  169),  and  the  whole  tubular  canal  of  the  cervix  is  being 
thinned  and  drawn  up ;  for  we  must  remember  that  in  over-distention  of  the 
uterus,  as  in  cases  of  hydramnion  or  twins,  or  in  the  relaxed  state  of  some 
multiparous  uteri,  or  where  there  has  been  wide  laceration,  the  cervix  gapes  in 
the  last  month,  and  that  a  low  position  of  the  fetus  flattens  the  cervix  between 
the  head  and  the  pelvic  floor  (Fig.  175). 


Fig.  1S5—  Pelvic  floor  before  distention  (modified  from  a  frozen  section  by  Braun  and  Zweifel,  one- 
third  natural  size) :  the  edema  and  thickening  seem  excessive,  but  Webster's  measurements  show  that 
this  floor  is  rather  thinner  than  the  average. 


We  are  warned  that  labor  is  actually  under  way  by  the  following  signs : 

1.  Irritability  of  the  bladder  and  the  rectum  becoming  more  marked  than 
before,  micturition  being  particularly  affected. 

2.  The  "show" — an  escape  of  blood-streaked  mucus,  due  to  slight  lacera- 
tions of  the  cervix.     This  sign  is  not  constant. 

3.  Expulsion  of  the  mucus  plug  from  the  cervix — a  sign  not  often  detected. 

4.  Increased  secretion.     Both  cervical  and  vaginal  mucus  is  poured  out  in 


THE    PHYSIOLOGY    OF  LABOR. 


385 


such  a  manner  that  when  the  passages  seem  soaked  and  softened  with  free 
mucilaginous  discharge  we  may  expect  to  find  cervical  dilatation  making  good 
progress. 

5.  Rhythmical  uterine  pains.  The  most  conclusive  symptom  of  beginning 
labor  is  the  occurrence  of  regularly  recurring  pains,  with  lessening  intervals 
and  increasing  force,  and  the  most  conclusive  sign  is  that  stated  above — 
namely,  beginning  dilatation  of  the  cervix. 

Stages  of  Labor. — The  first  stage,  better  called  the  dilatation  stage,  ends 
with  the  complete  canalization  of  the  utero-cervical  zone.  The  second  stage, 
the  stage  of  expulsion,  ends  with  the  birth  of  the  child.  The  third  or  placental 
stage  ends  with  complete  evacuation  and  lasting  retraction  of  the  uterus.18 

The  First  Stage,  or  the  Dilatation  Stage. — When  labor  is  fairly  started  the 
contractions  of  the  uterus  assume  a  certain  regularity,  characterized  by  decreas- 


Fig.  186.— Fully-distended  pelvic  floor  (over  one-third  life  size). 


iug  intervals  and  by  increasing  force  and  painfulness.  Occurring  at  first  about 
every  half-hour  and  only  slightly  discomforting,  with  some  sense  of  pressure, 
the  contractions  gradually  run  closer  together  until,  toward  the  end  of  dilatation, 
they  give  but  momentary  intervals  of  relief.  The  pain  is  located  as  a  rule  in 
the  sacral  region,  and  later  extends  to  the  lower  abdomen  or  down  the  thighs. 
The  patient  is  restless,  standing,  sitting,  moving,  tossing,  wringing  her  hands, 
seizing  on  a  support,  calling  for  pressure  against  the  sacrum,  or  begging  for  re- 
lief. Her  outcry  is  involuntary,  high-pitched,  or  apologetic,  an  impatient  pro- 
test, or  a  plaint.  She  can  be  persuaded  with  difficulty  that  any  progress  is 
being  made  by  such  colic,  seemingly  futile.  Her  cries  are  not  like  those  of 
the  second  stage,  which  is  marked  by  a  transition  to  the  groan  or  grunt  of  effort 
as  she  closes  the  glottis  and  strives  to  expel  the  child.  The  maternal  pulse 
increases  in  frequency  during  a  uterine  contraction,  while  the  fetal  pulse  is 
retarded  at  the  acme  of  the  pain.     The  temperature  in  normal  labor  rarely 


386 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


rises  1°  F.  Urine  is  freely  secreted  during  this  stage,  and  attacks  of  shiver- 
ing or  vomiting  may  occur  toward  its  end.  With  each  pain  the  cervix  grows 
tense,  the  border  becoming  sharp  and  the  membranes  protruding,  to  retreat 
again  as  the  edges  relax.  Gradually  yielding  and  softening,  with  abundant 
mucus-secretion,  the  retreating  edges  permit  the  membranes  to  rest  broadly  on 
the  pelvic  floor.  When  the  opening  measures  7.6  centimeters  (3  inches)  the 
bag  of  waters  usually  gives  way  and  the  "fore- waters  "escape,  clear  or  milky, 
with  particles  of  vernix  caseosum,  while  the  bulk  of  the  amniotic  fluid  is  held 
back  by  the  ball-valve  action  of  the  head.  After  a  pause  pains  recur  and  the 
head  descends,  and  the  rim  of  the  cervix  is  pushed  back  against  the  pelvic 
walls  until  its  edges  are  hardly  perceptible,  the  cervix  being  flattened  against 
and  practically  continuous  with  the  vaginal  walls. 

Tlie  duration  of  the  stage  of  dilatation  varies  from  two  hours  to  several 


(2>}ln  labor, 
flilly  distended 

Fig.  187  —Diagram  of  the  pelvic  floor  before  and  during  the  process  of  thinning  or  stretching.    It  will 
be  seen  that  the  structure  is  thinned  rather  than  driven  forward  (one-third  natural  size). 

days.  In  the  primipara  twenty-four  hours  is  not  uncommon,  and  the  length 
increases  with  the  patient's  age,  averaging  over  thirty  hours  at  forty  years 
(Decterlin).  To  give  a  figure  for  the  student  to  remember,  we  say  that  the 
average  duration  in  the  primipara  is  fifteen  hours,  in  the  multipara  eight  hours. 
The  Second  Stage,  or  the  Stage  of  Expulsion. — We  are  not  here  concerned 
with  the  mechanism,  which  will  be  treated  later  (p.  480).  The  patient  has 
a  fully-dilated  cervix,  ruptured  membranes,  and  a  fetal  head  resting  on 
the  pelvic  floor.  The  character  of  the  pain  changes ;  it  is  no  longer  teasing 
and  inefficient ;  the  impulse  to  drive  out  the  great  mass  that  presses  toward 
the  outlet  -brings  about  an  effort  by  the  diaphragm  and  abdominal  muscles 


THE   PHYSIOLOGY    OF  LABOR. 


387 


with  closed  glottis ;  steadying  herself  or  pulling  hard  on  sheet  or  assistant, 
she  strains  to  bring  all  her  strength  to  bear ;  instinctively,  as  in  the  savage 
races,  she  takes  the  semi-recumbent  posture  that  brings  the  uterus  upright ; 
and  her  outcry  is  the  groan  of  great  effort  or  the  moan  of  ended  exertion. 
With  each  pain  the  pelvic  floor  bulges  and  then  recedes ;  the  vulva  gapes 


Fig.  188.— Pelvic  floor  after  the  escape  of  the  head  (one-third  natural  size)  ■  constructed  from  the 
Zweifel  frozen  section  to  show  the  pushing  forward  of  the  anterior  vulvar  commissure  also,  and  the 
remarkable  way  in  which  the  child  is  packed  into  the  birth-canal.  The  passage  of  this  head  through 
the  pelvic  cavity  might  well  result  in  rupture  of  the  uterus. 

and  the  head  appears ;  the  parts  behind  the  outlet  grow  thinner  and  more 
dangerously  tense ;  the  acme  of  suffering  has  arrived.  As  the  head  protrudes 
through  the  opening  the  pains  grow  stormy,  and,  reckless  of  injury,  the  mother 
drives  out  the  torturing  obstruction.  The  fourchette  slips  back  over  the  face 
and  is  snugly  applied  to  the  neck  or  shoulder  (Fig.  188).  Now  occurs  a  pause 
of  from  one  to  five  minutes.     The  child  may  grow  dusky,  or  may  attempt 


388  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

to  breathe,  thus  drawing  into  the  air-passages  fluids  taken  into  the  mouth. 
Usually  the  next  pain  expels  the  trunk,  which  is  followed  by  a  gush  of  liquor 
arunii,  with  some  blood.  Tlie  duration  of  the  expulsion  stage  varies  from  ten 
minutes  to  six  hours.  In  prirniparse  the  average  is  two  hours,  in  multipara? 
one  hour. 

Changes  in  the  Pelvic  Floor. — The  pelvic  floor  is  the  fleshy  diaphragm 
dovetailed  into  the  bony  outlet  of  the  pelvis.  It  is  about  5  centimeters  (2  inches) 
in  thickness,  concave  above  and  covered  with  peritoneum,  and  convex  in  shape 
on  its  lower  skin-surface.  Between  these  surfaces  lie  fascia?,  muscles,  connective 
tissue,  and  fat,  named  in  the  order  of  their  physiological  importance.  Through 
the  floor  run  three  slits,  the  urethra,  the  vagina,  and  the  rectum-anus.  The 
axes  of  these  openings  are  oblique  (Fig.  187),  so  that  direct  pressure  from  above 


Fig.  189.— Pelvic  floor  seen  in  axial  coronal  section ;  one-third  actual  size  (modified  from  Hart). 

tends  to  close  the  openings  by  pressing  their  walls  together.  Ordinarily  their 
capacity  for  distention  is  limited,  but  the  remarkable  character  of  the  pelvic 
floor  is  that,  whereas  the  chief  function  of  this  unique  structure  is  to  form  a 
solid  and  unbroken  support  for  the  organs  above  it  under  all  conditions  of 
strain,  at  certain  moments  it  must,  without  injury,  efface  itself,  and  open  up 
to  the  size  of  its  entire  length  and  breadth.  We  shall  consider  the  changes 
that  bring  about  this  result. 

Hart,  studying  frozen  sections  mainly,19  observed  that  the  vaginal  slit  divides 
the  structure  into  an  anterior  part,  which  he  named  the  pubic  segment,  triangu- 
lar in  shape,  composed  of  retropubic  fat,  bladder,  urethra,  ami  anterior  vaginal 
wall,  attached  (loosely)  to  the  pubes  ;  and  a  much  larger  and  stronger  posterior 
part,  the  sacral  segment,  between  the  rear  vaginal  wall  and  the  posterior  bony 
wall,  including  the  anus  and  part  of  the  rectum.     Symington20  considers  that 


THE   PHYSIOLOGY   OF  LABOR.  389 

the  rectum  and  bladder  and  the  upper  vagina,  like  the  uterus,  should  not  be 
regarded  as  parts  of  the  floor,  but  as  organs  resting  upon  it.  Webster21  holds 
that  the  bladder  is  imbedded  in  the  pelvic  floor,  and  that  the  vagina  and  cervix 
are  parts  of  it,  together  with  the  rectum  from  the  coccyx  down.  In  the  illustra- 
tion (Fig.  189),  for  obvious  reasons,  the  bladder  and  cervix  have  been  omitted. 

Late  in  pregnancy  the  changes  that  belong  to  the  pelvic  floor  are  relaxation 
from  edema,  moderate  increase  in  thickness,  and  a  low  droop  or  "  bulging 
downward."  All  these  changes  favor  the  stretching  that  is  to  come.  The  main- 
tenance of  its  former  axis  by  the  vagina,  its  distance  from  the  symphysis,  the 
shape  of  the  pelvic  floor  at  this  time,  and  the  low  position  before  it  is  opened 
up  into  an  oblique  hernial  canal  are  shown  in  Figures  185,  187,  and  189. 

During  labor,  in  the  dilatation  stage  the  parts  anterior  to  the  vagina  are 
restrained  from  being  driven  down  by  the  upward  traction  of  the  longitudinal 
fibres  of  the  uterus  on  the  anterior  lip  of  the  cervix,  to  which  the  bladder  is 
attached.  As  the  os  is  drawn  up  the  bladder  and  urethra  are  somewhat  elevated, 
the  former  coming  to  lie  at  the  back  and  partly  above  the  pubes,  flatly  com- 
pressed against  the  bone,  together  with  the  urethra,  by  the  descending  head. 
The  utero-vesical  pouch  of  peritoneum  is  stripped  upward  from  the  bladder 
(Webster),  and  the  urethra  is  not  elongated. 

The  parts  posterior  to  the  vagina,  composing  the  sacral  segment,  are  of  more 
clinical  interest.  The  change  in  position  here  is  rather  a  pushing  backward 
than  a  driving  downward,  and  is  accompanied  with  excessive  thinning.  The 
centre  of  the  perineal  skin-surface,  and  with  it  the  important  tendinous  centre 
of  the  perineum,  is  only  driven  down  in  the  long  axis  of  the  body  2.5  cen- 
timeters (1  inch),  while  the  5-centimeter  (2-inch)  perineal  pyramid  is  atten- 
uated to  4  or  even  to  2  millimeters  (^  or  ^  inch).*  The  sacral  segment  is 
moderately  elongated.  From  the  tip  of  the  sacrum  to  the  posterior  commis- 
sure before  labor  is  about  16.6  centimeters  (6^  inches).  During  full  stretching 
by  the  head  the  Varnier  section  measures  19  centimeters  (7-j  inches),  and  the 
writer's  hospital  measurements  averaged  18  centimeters  (7£  inches).  The 
sphincter  ani  gapes  a  little  over  an  inch  (Hart),  and  assumes  the  form  of  a  D 
laid  on  its  side  (thus,  o),  while  the  anus  is  displaced  backward  (Fig.  187,  A,  A,  a). 

The  figures  may  be  summarized  as  follows : — 

Centimeters.    Inches. 

Thickness  of  the  pelvic  floor  in  front  of  the  anus,  in  nullipara  (Webster)  ...  3.3  1J 

"         "     at  term,  before  stretching 7  2J 

"         "     moderately  distended 2.5  1 

"        "     fully  distended 3  J 

Projection  of  pelvic  floor,  in  nullipara 2.5  1 

"         "      at  term,  before  stretching 7  2| 

"         "      at  greatest  distention 9  3| 

"         "      on  twelfth  day  of  puerperium 2.5  1 

Length  of  perineal  body,  from  fourchette  to  anus,  in  nullipara 3.3  \\ 

"  "       after  complete  dilatation  by  the  head .6.5  2J 

*  The  figures  used  in  this  discussion  are  drawn  in  a  certain  degree  from  Webster  and  Varnier, 
but  are  mainly  based  on  an  independent  study  of  eighteen  frozen  sections  that  range  from  the 
eighth  month  to  the  middle  of  the  expulsion  stage,  and  are  corrected  by  a  number  of  lead-tape 
tracings  of  the  pelvic  floor  during  labor. 


390  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

The  Third  Stage  of  Labor,  or  the  Placental  Stage. — The  processes  whereby 
the  placenta  is  separated  and  expelled  and  retraction  of  the  uterus  is  secured  are 
given  on  page  490.  Clinically  we  note  that  the  fundus  is  hardened  by  firm 
uterine  contraction,  and  is  located  above  the  brim,  but  below  the  level  of  the 
navel.  Blood  trickles  in  small  quantity  from  the  vagina  during  the  pause, 
the  total  blood-loss  in  a  labor  averaging  less  than  500  grams  (18  ounces).  After 
a  rest  rhythmic  uterine  activity  is  renewed,  and  the  placenta  comes  away,  fol- 
lowed by  the  membranes,  and  the  corpus  is  found  to  have  but  half  the  former 
breadth  and  to  be  halfway  to  the  navel.  Very  moderate  stimuli — such  as  fric- 
tion, nursing,  a  douche  of  hot  water — will  now  produce  good  contraction, 
whereas  strong  excitors  may  have  failed  while  the  uterus  was  distended. 

The  average  duration  of  the  -placental  stage  is  from  twenty  to  thirty  min- 
utes. The  placenta  may  follow  the  child  at  once,  or  it  may  remain  two  hours. 
After  that  time  the  case  belongs  under  the  head  of  Pathology. 

Duration  of  Labor. — The  length  of  labor  varies  within  very  wide  limits, 
and  our  definite  statements  of  averages  do  not  claim  exactness.  The  exact  hour 
of  the  onset  of  labor  is  often  impossible  to  fix.  Labor  is  usually  longer  in  the 
primipara  than  in  the  pluripara,  on  account  of  the  greater  resistance  of  the 
soft  parts  during  the  first  delivery.  It  is  longer,  as  a  rule,  in  the  very  young 
and  in  the  elderly  primipara,  and  in  the  stout  than  in  women  of  slighter  build. 
Spiegelberg's  506  cases  are  commonly  quoted,  wherein  the  three  stages  in  the 
primipara  are  averaged  respectively  at  fifteen  hours,  two  hours,  and  half  an 
hour,  with  a  total  of  about  seventeen  hours,  while  the  multipara  is  listed  at 
eight,  one,  and  one-half,  the  total  being  given  as  eleven  hours.  Many  of  the 
text-books  are  non-committal.  The  majority,  however,  estimate  the  duration 
of  labor  in  the  multipara  at  eight  hours — not  varying  greatly  from  Spiegel- 
berg's figures  in  other  respects. 

Table  of  Averctge  Duration  of  Stages  of  Labor  in  Hours. 


Primipara 

Multipara 


Spiegelberg 22  states  that  labor  most  frequently  begins  between  10  and  12 
o'clock  in  the  evening,  and  the  end  of  labor  occurs  twice  as  often  between  9 
p.  M.  and  9  A.  M.  as  in  the  other  twelve  hours.  AVest23  found,  in  2019  cases, 
40  per  cent,  delivered  between  11  p.m.  and  7  a.m.,  and  the  most  favored 
time  is  between  midnight  and  three  in  the  morning.  A  larger  number  of  rapid 
labors  are  said  to  occur  in  summer  than  in  winter  (107  :  100). 


THE    CONDUCT    OF  NORMAL    LABOR. 


391 


REFERENCE    LIST. 


1.  Lusk:  Midwifery,  1892,  p.  124. 

2.  Archivfiir  Oyndkoloyie,  Bd.  xi.  p.  49. 

3.  Wiener  medicinische  Jahrbuch,  1872,  1873. 

4.  Cohnstein :    Archiv  fur    Oyndkoloyie,    Bd. 

xviii.  p.  394. 

5.  New  York  Journal  of  Gynecology  and  Ob- 

stetrics,   June,    1892,    and    November, 
1893. 

6.  Parvin  :   Obstetrics,  1890,  p.  362. 

7.  Cenlralblatl  fib-  Oyndkoloyie,  1884,  p.   648, 

and  1S85,  p.  625. 

8.  Winter:  Zwei  Medianschn.,  Berlin,  1889. 

9.  Lusk:  Midwifery,  1892,  p.  13S. 

10.  Barbour  and  Webster:  Edinburgh  Lab.  Re- 

ports, vol.  ii.,  1890,  p.  31. 

11.  Schroeder  :  Schwangere  unci  Kreissende  Ute- 

rus, 1SS6. 

12.  A  clear  epitome  with  partial  bibliography 


is  given  in  Jaggard's  section  of  Hirst's 
American  System  of  Obstetrics,  p.  333. 

13.  Archivfiir  Oyndkoloyie,  Band  xv. 

14.  "  Zur  Phys.  u.  Path,  morphol.  d.  Gebar- 

mutter,"  Gyn.  Klinik,  1885,  p.  398. 

15.  Ribemont-Dessaignes-Lepage:  Precis  d'  06- 

stetrique,  1894,  p.  332, 

16.  Pinard  and  Varnier:  Anatomic  Obstetricale. 

17.  Precis  d' Obstetrique,  p.  335. 

18.  Jewett:     Outlines   of    Obstetrics,    Saunders, 

Philadelphia,  1894,  p.  109. 

19.  Structural    Anatomy   of    the    Pelvic    Floor, 

Edinburgh,   1880. 

20.  Edinburgh  Medical  Journal,  March,  1889. 

21.  Researches  in  Female  Pelvic  Anatomy,  1892. 

22.  Lehrbuch,  1891,  p.  147 ;   Monatsschrift  fur 

Oeburtshiilfe,  1868,  p.  279. 

23.  American  Medical  Journal,  1854. 


II.  THE  CONDUCT  OF  NORMAL  LABOR. 

1.  Antisepsis. 

Nowhere  do  we  find  more  striking  proofs  of  the  value  of  the  antiseptic 
system  than  is  shown  in  the  diminished  puerperal  mortality  and  morbidity 
in  hospitals  since  the  introduction  of  antisepsis  into  obstetric  practice. 
Before  the  advent  of  Listerism  the  usual  death-rate  from  childbed  fever 
in  lying-in  hospitals  was  from  2  to  10  per  cent.,  and  in  so-called  "  epidemics" 
this  limit  was  often  exceeded.  In  the  women  who  survived,  feverless  childbeds 
were  comparatively  infrequent.  Under  antiseptic  methods  the  mortality  from 
sepsis  in  well-managed  institutions  is  less  than  1  in  200,  and  the  morbidity 
does  not  exceed  10  per  cent. 

A  few  examples  will  suffice  to  show  what  is  possible  under  the  present 
perfected  system  of  aseptic  obstetrics.  Professors  Groth,  Netzel,  and  Sonders 
of  Stockholm  report1  17,862  births  under  their  direction  (1880-89),  with  1 
death  in  344,  or  .29  per  cent.  In  Copenhagen  (1888-89),  in  1218  hospital 
deliveries  the  death-rate  was  .24  per  cent.  Slawiansky2  tabulates  the  results 
of  176,646  deliveries  in  fifty-three  hospitals  of  Russia  (1881-89),  showing  a 
morbidity  of  8.57  and  a  mortality  of  .38  percent.  Leopold3  records  3089 
cases  (from  May,  1885,  to  May,  1887)  without  a  death  from  septic  infection. 

The  Boston  Lying-in  Hospital  (1891)  recorded  550  deliveries  with  no 
death  from  septic  causes.  In  1892  there  were  515  confinements  with  but 
1   fatal  case  from  septicemia — a  mortality  of  less  than  0.1  per  cent,  for  the 

1  Verhandlungen  des  X.  Internationalen  Med.  Cony.,  B.  111.  2  Ibid. 

3  Deutsche  med.  Wochenschrift,  vol.  xiii.  No.  25. 


392  AMERICAN    TEXT-BOOK   OF    OBSTETRICS. 

two  years.1  In  the  Sloane  Maternity,  New  York  City,  there  has  been  thus 
far  but  1  septic  death  in  3000  deliveries.2  In  the  New  York  Maternity 
Hospital  957  women  were  delivered  during  the  three  years  ending  Oct.  1, 
1893,  without  a  death  from  sepsis.3 

W  hile  in  pre-antiseptic  times  the  puerperal  mortality  was  many  times  greater 
in  public  institutions  than  in  private  practice,  to-day  the  pauper  delivered  in  a 
hospital  is  exposed  to  less  risk  than  are  the  well-to-do  classes  who  are  confined  in 
their  own  homes.  Insurance  reports  show  that  of  all  deaths  in  women  between 
the  ages  of  nineteen  and  twenty-nine  more  than  18  per  cent.,  and  between 
twenty-nine  and  thirty-nine  years  more  than  13  per  cent.,  are  due  to  puerperal 
causes.  From  65  to  75  per  cent,  of  puerperal  deaths  are  attributable  to  sepsis. 
It  is  fair  to  assume  that  these  statistics  have  to  do  almost  wholly  with  a  class 
who  are  delivered  outside  of  hospitals.  This  indicates  a  mortality  that  is  truly 
appalling,  especially  when  one  reflects  that  it  falls  upon  women  in  the  prime 
of  life  and  usefulness,  and  is  the  result  of  a  preventable  disease.  Yet  the 
disastrous  effects  of  puerperal  infection  are  not  represented  by  the  mortalitv 
alone.  Thousands  of  invalid  mothers  owe  their  impaired  health  to  the  milder 
grades  of  sepsis  in  childbed.  No  stronger  evidence  could  be  offered  than  is 
afforded  by  the  foregoing  facts  of  the  need  for  improvement  in  the  obstetric 
methods  of  the  general  practitioner. 

Obstetric  antisepsis  dates  from  1847.  To  Ignatius  P.  Semmelweis,  a 
young  Hungarian  who  at  that  time  held  the  position  of  assistant  in  the  lying-in 
department  of  the  Vienna  General  Hospital,  belongs  the  credit  of  first  demon- 
strating its  efficacy.  •  The  obstetric  service  of  the  hospital  was  divided  into  two 
sections,  in  one  of  which  instruction  was  given  to  midwives,  in  the  other  to 
medical  students.  It  was  with  the  latter  that  Semmelweis  was  connected.  The 
students  in  this  department  were  at  the  same  time  actively  engaged  in  the  pur- 
suit of  practical  anatomy  and  pathology.  The  women  were  delivered  by 
students  who  for  a  considerable  portion  of  their  time  were  occupied  with  the 
operations  of  the  dead-house  and  the  dissecting-room.  They  took  no  precau- 
tions to  cleanse  themselves  except  to  wash  their  hands  with  soap  and  water, 
and  they  made  examinations  ad  libitum.  The  death-rate  was  excessive,  reach- 
ing nearly  10  per  cent,  of  the  women  delivered. 

Horrified  at  this  frightful  mortality,  Semmelweis  bent  his  energies  to  find- 
ing the  cause.  He  was  struck  with  the  fact  that  in  the  midwives'  clinic  the 
death-rate  was  little  more  than  3  in  every  100  women  confined.  The  records 
showed  also  that  women  delivered  before  admission  nearly  all  escaped.  It 
appeared,  too,  that  prolonged  labors  in  the  students'  clinic  were  almost  invari- 
ably followed  by  death,  while  in  the  midwives'  section  the  length  of  the  labor 
made  little  difference  in  the  mortality.  During  the  time  that  Semmelweis  was 
engaged  in  his  investigations  Prof.  Kolletsehka,  one  of  his  associates,  lost  his 
life  by  a  dissection-wound.     The  symptoms  of  his  colleague's  illness  were 

1  Communication  to  the  writer  from  Dr.  Charles  M.  C4reen,  Sept..  1893. 

2  Personal  letter  from  Prof.  J.  W.  McLane,  Oct.,  1S93. 

3  Personal  communication  from  Dr.  Robert  A.  Murray,  Oct.,  1893. 


THE    CONDUCT    OF  NORMAL    LABOR.  393 

entirely  similar  to  those  of  the  fatal  malady  which  was  raging  in  his  own 
wards.  Impressed  with  the  identity  of  the  two  diseases,  it  dawned  upon  him 
that  the  cause  of  the  deadly  scourge  was  to  be  found  in  the  infected  hands  of 
the  students  who  attended  the  labors. 

In  May,  1847,  he  established  the  order  that  students  before  taking  charge 
of  a  labor  case  should  wash  their  hands  in  chlorin-water  or  in  a  solution  of 
chlorinated  lime,  and  he  restricted  the  number  of  examinations.  The  result 
was  an  immediate  fall  in  the  death-rate.  In  six  months  it  had  dropped  from 
nine  or  ten  to  three  per  hundred,  and  in  the  second  year  of  the  new  regime  it 
did  not  exceed  1.5  per  cent.' 

Soon  after  its  introduction  into  surgery  by  Sir  Joseph  Lister  in  1866  anti- 
sepsis began  to  gain  a  permanent  foothold  in  obstetrics.  First  adopted  in 
1870  by  Stadfeldt  of  Copenhagen,  it  was  taken  up  by  the  principal  maternities 
of  Europe,  and  to-day,  with  many  improvements  in  the  technique,  it  is  univer- 
sally practised  in  the  lying-in  hospitals  of  the  world. 

Practical  Rules  for  Disinfection. 

Instruments,  Utensils,  and  Dressings. — The  most  efficient  of  all  germicidal 
agents  is  heat.  For  instruments,  utensils,  sutures,  and  dressings  that  will  not 
be  injured  by  high  temperatures  heat  affords  the  best  means  of  disinfection. 
Either  of  three  methods,  dry  heat,  boiling,  or  steaming,  may  be  employed. 

Dry  Heat. — For  most  utensils  exposure  in  an  oven  is  a  convenient  and 
effective  method  of  sterilizing.  It  is  necessary  that  the  temperature  reach 
284°  F.  For  greater  accuracy  in  regulating  the  temperature  a  thermom- 
eter specially  made  for  the  purpose  may  be  used.  As  some  time  will  be 
required  to  bring  the  instruments  to  the  necessary  degree  of  heat,  the 
exposure  should  be  maintained  for  at  least  fifteen  minutes  to  ensure  proper 
sterilization. 

Boiling. — The  best  method  of  sterilizing  most  instruments  is  boiling  them 
ten  minutes  in  water.  The  addition  of  1.5  per  cent,  of  washing  soda  to  the 
water  helps  to  remove  greasy  matter,  tends  to  prevent  steel  instruments  from 
rusting,  and  increases  its  germicidal  action.  The  soda  should,  if  possible, 
be  chemically  pure.  This  method  has  the  advantage  that  it  is  available  in 
any  household.  All  that  is  needed  is  a  vessel  large  enough  to  hold  the 
necessary  instruments  and  appliances,  and  a  range  fire,  gas  stove,  or  even  a 
large  alcohol  lamp.  In  emergency  no  more  elaborate  apparatus  is  required 
than  a  common  dish-pan.  Place  in  it  the  instruments,  silk  or  silk-wrorm 
sutures,  sponge  compresses,  and  other  materials  to  be  sterilized,  cover  them 
with  wrater,  and  boil  for  the  requisite  length  of  time.  Turn  off  the  water, 
and  the  pan  serves  as  an  aseptic  instrument-tray. 

Steaming.— Sterilization  by  steam  requires  special  apparatus.  Numerous 
appliances  are  to  be  had  for  the  purpose,  one  of  the  most  economical  of 
which  is  the  Arnold  steam-cooker.     This  process  is  available  for  practically 

1  For  many  of  these  facts  the  writer  is  indebted  to  an  address  by  C.  T.  Cullingworth,  M.  D., 
F.  E.  C.  P.,  entitled  Puerperal  Fever  a  Preventable  Disease.  — . 


394  AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 

all  dressings,  and  utensils  not  too  bulky  to  be  contained  in  the  sterilizer.  It 
is  well  to  place  the  articles  to  be  sterilized  in  a  wire  basket  or  a  cloth  bag  in 
which  they  may  be  lowered  into  the  steam-chamber.  This  facilitates  hand- 
ling. The  time  required  for  sterilization  is  from  ten  minutes  to  an  hour, 
according  to  the  bulk  and  character  of  the  materials.  Dressings  need  the 
longest  exposure. 

In  the  labor  ward  of  a  hospital  a  steam-sterilizer  may  be  kept  in  opera- 
tion during  the  labor,  and  compresses,  sutures,  dressings,  etc.,  may  be  taken 
direct  from  the  steam-chamber  as  they  are  wanted  for  use. 

Chemical  Antiseptics. — Among  the  chemical  agents  most  commonly  em- 
ployed for  obstetric  antisepsis  are  the  mercuric  chlorid  dissolved  in  water, 
in  strength  of  from  1  :  2000  to  1  :  500,  the  mercuric  iodid  in  similar  propor- 
tion, the  peroxid  of  hydrogen  (15-volume  solution),  the  liquor  soda;  chloratre 
diluted  with  9  volumes  of  water,  a  2  per  cent,  creolin  mixture  (in  water), 
and  a  2  to  5  per  cent,  solution  of  carbolic  acid.  The  order  in  which  they 
are  named  is  substantially  that  of  their  germicidal  potency. 

The  practical  efficiency  of  mercuric  chlorid  (corrosive  sublimate)  is  greatly 
increased  by  the  addition  to  the  solution  of  five  parts  of  hydrochloric,  tar- 
taric, or  acetic  acid  for  each  part  of  the  sublimate,  since  in  neutral  solutions 
of  that  salt  the  mercury  is  precipitated  as  an  albuminate  on  contact  with  blood 
or  with  other  albuminous  liquids.  The  acid,  moreover,  serves  to  protect  the 
solution  against  impairment  of  strength  by  contact  with  the  alkaline  fluids  of 
the  tissues.  The  mercuric  chlorid  is  decomposed  by  alkalies.  The  mercuric 
iodid  (biniodid  of  mercury)  requires  the  addition  of  an  equal  weight  of  the 
iodid  of  potassium  to  render  it  freely  soluble.  With  this  salt  no  acid  is 
required.  Neutral  solutions  of  the  mercuric  iodid  yield  no  precipitate  with 
albumin.  The  chlorated-soda  solution,  the  peroxid  of  hydrogen,  and  the 
creolin  mixture  have  the  advantage  of  being  practically  non-poisonous,  and 
they  are  therefore  more  suitable  to  be  trusted  to  the  nurse  than  are  the  mer- 
curial preparations. 

The  Obstetrician. — The  obstetrician  should  be  clean  ;  especially  must  his 
hands  be  clean,  and  he  should  wear  clean  clothing.  It  is  well  to  avoid  eon- 
tact  with  pathological  material  and,  so  far  as  possible,  with  other  sources  of 
wound-infection. 

It  is  impossible  to  lay  down  rules  which  alone  will  make  an  aseptic  prac- 
titioner. The  obstetrician  must  be  possessed  of  an  aseptic  instinct,  and  this 
is  a  matter  which  comes  of  training  and  a  keen  appreciation  of  the  possible 
sources  and  modes  of  infection. 

During  attendance  upon  a  labor  the  obstetrician  should  wear  a  fresh- 
laundered  gown  or  a  clean  apron  large  enough  to  prevent  contact  of  his 
hands  with  his  clothing.  His  hands  and  forearms  are  to  be  cleansed  thor- 
oughly and  disinfected  before  the  first  examination,  and  before  each  subse- 
quent contact  with  the  genitals  if  they  have  in  the  meantime  touched  any- 
thing that  is  not  aseptic. 

Hand  Disinfection. — Furbringer  Method. — For  the   disinfection  of  the 


THE    CONDUCT    OF   NORMAL    LABOR.  395 

hands  the  following  method,  which  is  substantially  that  of  Fiirbringer,  is 
recommended  : 

1.  Keep  the  nails  cut  short  and  clean  them  dry. 

2.  Brush  the  hands  and  forearms  systematically  for  five  or  ten  minutes 
with  a  hand-brush,  with  soap  and  water  as  hot  as  can  be  borne.  Special  care 
must  be  taken  to  brush  thoroughly  the  nails,  the  finger-tips,  and  the  sides 
of  the  fingers.  The  water  should  be  changed  two  or  three  times,  and  the 
scrubbing  completed  in   running  water. 

3.  Soak  well  with  alcohol  (80  per  cent.)  and,  before  it  evaporates, 

4.  Immerse  for  five  minutes  in  a  hot  solution  of  mercuric  chlorid  (1  :  2000 
to  1  :  500),  or  in  a  3  per  cent,  solution  of  carbolic  acid. 

The  foregoing  technic,  even  without  the  alcohol,  though  it  does  not  meet 
the  requirements  of  laboratory  tests,  will  be  found  satisfactory  from  the 
clinical  standpoint,  if  faithfully  carried  out. 

Undoubtedly,  the  most  essential  step  in  the  process  is  the  soap-and-water 
scrubbing.  It  not  only  removes  the  greater  part  of  the  offending  material, 
but  it  is  also  indispensable  to  the  proper  action  of  the  antiseptic  solution. 
The  latter  can  penetrate  the  skin  only  after  the  oily  matter  has  been  removed 
and  after  the  skin  is  thoroughly  wet.  The  use  of  alcohol  helps  the  action  of  the 
chemical  solution  by  dehydrating  the  skin  and  rendering  it  hygroscopic,  thus 
favoring  penetration  of  the  solution.     It  is  to  some  extent  also  a  solvent  for  fat. 

When  summoned  to  a  case  of  labor  immediately  after  a  septic  contact, 
besides  the  usual  care  in  disinfection,  the  obstetrician  should  wear  sterilized 
rubber  gloves.  Lacking  gloves,  it  is  often  possible  to  manage  the  birth  even 
without  direct  contact  with  the  genitals  of  the  patient,  the  required  manip- 
ulations being  conducted  through  the  intervention  of  a  sterilized  towel  well 
saturated  with  the  antiseptic  solution. 

Permanganate  Method. — AVelch,  of  the  Johns  Hopkins  Hospital  at  Bal- 
timore, recommends  the  following  procedure,  which  is  known  as  the  perman- 
ganate method.  By  it  the  hands,  it  is  claimed,  may  be  rendered  practically 
sterile  to  culture  tests.  This,  however,  is  true  only  of  the  surface  of  the 
skin  and  that  only  for  a  period  of  not  many  minutes.  The  serins  always 
present  in  the  deeper  layers  of  the  cuticle  are  not  destroyed  and  they  soon 
gain  access  to  the  surface. 

1.  The  nails  are  cut  short  and  carefully  cleaned. 

2.  The  hands  and  forearms  are  scrubbed  for  five  minutes  with  soap  and  water. 
The  brush  before  using  is  sterilized  by  steam,  and  the  water,  which  is  as  hot  as 
can  be  borne,  is  frequently  changed.    The  soap  is  rinsed  off  with  plain  water. 

3.  The  hands  are  next  immersed  in  a  warm  solution  of  permanganate  of 
potassium  until  of  a  deej)  brown  color.  The  solution  is  best  made  with  dis- 
tilled, or  at  least  boiled,  water  and  it  should  be  saturated. 

4.  The  hands  are  next  held  in  a  warm  saturated  solution  of  oxalic  acid  in 
boiled  water  until  the  permanganate  stain  is  entirely  discharged. 

5.  After  rinsing  in  sterilized  water  the  hands  are  immersed  for  two  min- 
utes or  more  in  a  1  :  500  mercuric-chlorid  solution. 


396  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

The  most  effectual  safeguard  against  infection  by  the  hands  is  afforded 
by  the  use  of  rubber  gloves  which  have  been  boiled  in  normal  salt  solution 
for  fifteen  minutes.  The  hands  are  prepared,  before  putting  on  the  gloves, 
with  the  same  care  as  when  no  gloves  are  used.  This  is  necessary  for  the 
reason  that  the  gloves  may  be  torn  and  the  hand  partially  exposed. 

The  Nurse. — The  nurse  should  be  no  less  careful  than  the  obstetrician  in 
the  observance  of  all  antiseptic  details. 

The  Patient. — In  hospital  practice  the  patient  has  a  bath  and  a  change  of 
clothing  at  the  onset  of  labor.  In  all  cases  before  the  first  internal  examina- 
tion the  abdomen,  the  thighs,  and  the  vulva  are  cleansed  by  the  nursewith  soap 
and  warm  water.  The  soapy  water  is  rinsed  off  and  the  parts  are  well  bathed 
with  the  antiseptic  solution.  It  is  a  useful  precaution  to  cover  the  limbs  of 
the  patient,  when  she  takes  the  'bed,  with  a  pair  of  muslin  leggings  fresh  from 
the  sterilizer.  The  leggings  should  be  closed  below,  so  as  completely  to 
envelop  the  feet.  In  addition  to  this,  the  patient  and  the  entire  cot  may  be 
covered  with  a  sterilized  gauze  sheet.  During  the  first  stage  a  vulvar  dress- 
ing saturated  with  Thiersch's  solution  may  be  worn. 

Similar  precautions  are  not  all  practicable  in  private  practice,  nor  are  they 
all  necessary.  The  change  of  clothing,  the  preliminary  cleansing  and  disinfec- 
tion of  the  external  genitals  and  adjacent  surfaces,  and  the  aseptic  cleanliness  of 
everything  that  comes  in  contact  with  the  birth-canal  must  always  be  insisted 
upon. 

The  utility  of  prophylactic  vaginal  douches  is  a  question  which  has  pro- 
voked much  discussion.  Steffeck l  recommends  vaginal  irrigation  during  labor 
with  mercuric-chlorid  solution  at  intervals  of  two  hours,  rubbing  the  antisep- 
tic well  into  the  mucous  membrane  with  the  fingers. 

Doderlein 2  advises  scrubbing  the  vagina  with  a  preparation  of  creoliu  and 
mollin,  followed  by  a  ten-minutes'  douching  with  the  creolin  solution. 

Hofmeier3  favors  preliminary  disinfection,  especially  in  maternity  hospitals 
where  students  are  allowed  to  examine  the  patients  during  labor.  He  concludes, 
from  a  comparison  of  the  records  of  the  Wiirzburg  clinic  with  the  published 
statistics  of  other  like  institutions,  that,  with  preliminary  disinfection  and  the 
careful  observation  of  all  possible  antiseptic  precautions,  instruction  by  means 
of  examinations  during  labor  does  not  necessarily  increase  the  danger  of  infect- 
ing the  patient.  He  further  contends  that  thorough  disinfection  of  the  birth- 
canal  is  not  a  source  of  danger  to  the  mother,  as  has  been  claimed,  but  that  it 
results  in  a  diminished  puerperal  morbidity  and  mortality. 

Frommel 4  reports  over  five  hundred  cases  in  which  vaginal  injections  of 
the  corrosive-sublimate  solution  (1  :  2000)  were  employed,  and  where  in 
many  abnormal  cases  from  sixty  to  seventy  examinations  were  made  during 
the  patient's  stay  in  the  hospital,  the  clinic  being  open  to  about  one  hundred 
students,  and  being  also  used  for  the  training  of  midwives.     In  this  number 

1  "  Ueber  Disinfection  des  Weiblichen  Genital  Canals,"  Zeitschrift  fiir  Qeburtshtilfe,  vol.  xv. 
p.  395. 

2  "  Disinfection  des  Geburts-Canal,"  Archiv  fur  Gynakologie,  vol.  xxxiv.  111. 

3  Deutsche  med.  Wochensehrift,  1891,  No.  49.  *  Ibid.,  1892,  No.  10. 


THE    CONDUCT   OF  NORMAL    LABOR.  397 

of  patients  there  were  two  cases  of  sepsis  whose  infection  was  traceable  to  his 
clinic.  The  morbidity-rate  was  from  5.5  to  7.5  per  cent.  In  another  series  of 
cases,  where  external  disinfection  alone  was  practised,  the  morbidity  rose  to 
11.1    per  cent. 

Mermann  '  reports  the  results  of  seven  hundred  cases  without  the  employ- 
ment of  vaginal  douches  for  preliminary  disinfection.  He  records  a  morbidity- 
rate  of  6  per  cent.,  with  no  deaths  from  septic  infection.  In  the  last  two  hun- 
dred births  there  were  two  cases  of  mild  ophthalmia,  and  in  all  less  than  ten 
of  conjunctivitis  among  the  children.  Mermann  omits  internal  examinations 
whenever  practicable,  observing  the  progress  of  the  labor  by  abdominal  palpa- 
tion and  auscultation. 

Leopold  and  Goldberg 2  publish  the  statistics  of  several  thousand  deliveries 
with  and  without  the  employment  of  vaginal  disinfection.  Their  tables  show 
the  best  results  where  the  vaginal  douches  were  not  used.  They  recommend  the 
employment  of  abdominal  palpation  as  a  means  of  noting  the  progress  of  labor, 
and  the  restriction  of  vaginal  examinations  to  cases  of  dystocia,  except  when 
necessary  to  confirm  a  diagnosis  made  by  the  abdominal  method.  They  advise 
douches  in  operative  cases  and  in  all  others  where  previous  infection  is  suspected. 

Fischel  in  an  experience  of  880  births  at  the  Prague  Maternity  lost  nine 
women  from  sepsis  with  the  employment  of  preliminary  disinfection.  After 
stopping  the  use  of  the  irrigations,  in  a  series  of  933  cases  there  were  but  two 
deaths  due  to  infection,  and  a  year  later,  in  521  women  delivei'ed,  there  were 
no  deaths  from  that  cause. 

The  safer  course,  at  least  for  general  use,  is  undoubtedly  the  restriction  of 
internal  examinations  as  much  as  practicable,  and  of  the  prelimiuary  vaginal 
douche  to  cases  in  which  the  secretions  are  pathological.  In  the  presence  of 
purulent  gonorrheal  discharges  both  the  vaginal  and  cervical  canal,  as  well  as 
the  vulva,  ought  to  be  cleansed  carefully  with  soap  and  water  and  gentle  fric- 
tion with  the  fingers,  and  subsequently  flushed  well  with  the  antiseptic  solution. 
In  extreme  cases  the  disinfection  may  be  repeated  at  intervals  of  two  or  three 
hours  during  the  labor.  This  is  required  not  only  in  the  interests  of  asepsis 
for  the  mother,  but  as  a  prophylactic  against  ophthalmia  in  the  child.  Mer- 
curials, however,  are  not  suitable  for  the  purpose,  owing  to  the  danger  of 
mercurial  intoxication.  Mercury  has  been  found  in  the  stools  after  a  single 
vaginal  irrigation.  Some  of  the  non-toxic  disinfectants,  such  as  crcolin, 
peroxid  of  hydrogen,  or  the  chlorinated -soda  solution,  are  to  be  recommended. 

Antisepsis  in  the  Use  of  the  Catheter. — Should  the  patient  require  to  be 
catheterized  after  labor,  care  will  obviously  be  needed  to  prevent  infection 
of  the  vaginal  wounds  and  abrasions.  But  this  is  not  all.  Cystitis  of  the 
vesical  neck  frequently  results  from  infectious  material  carried  into  the  bladder 
during  the  use  of  the  catheter.  So  common  is  this  accident  that  patients  who 
have  repeatedly  been  catheterized  by  the  nurse,  even  with  ordinary  precautions, 
very  rarely  escape  some  degree  of  vesical  irritation,  and  they  often  suffer  from 
severe  inflammation  of  the  bladder  or  of  the  vesical  neck.  Pyelitis  even  may 
1  Centralblatt  fiir  Gyndkologie,  1892,  No.  99.  2  Deutsche  med.  Wochenschrift,  1S92,  No.  13. 


398  AMERICAN  TEXT-BOOK   OF   OBSTETRICS. 

result  by  extension  of  the  septic  process  from  the  vesical  mucosa  through  the 
ureters.  The  strictest  asepsis  must  therefore  be  observed  in  catheterizing  the 
bladder.  The  instrument  should  be  boiled  for  fifteen  minutes  in  water  con- 
taining 1J  per  cent,  of  sodium  carbonate  immediately  before  using,  and  this 
is  possible  even  with  soft-rubber  catheters  without  material  injury  to  the 
instrument.  It  should  then  be  handled  only  with  hands  that  have  pre- 
viously been  sterilized. 

The  patient  lies  upon  the  back  with  the  knees  drawn  apart.  The  labia 
are  to  be  held  apart,  either  by  the  patient  herself  or  by  an  assistant,  so  as  to 
expose  completely  the  meatus  urethrae,  and  so  held  until  the  instrument  is 
passed.  The  meatus,  the  vestibule,  and  all  the  surrounding  surfaces  are  to 
be  cleansed  with  soap  and  water,  and  subsequently  to  be  washed  with  the 
disinfectant  solution.  The  catheter,  well  lubricated  with  sterilized  vaselin, 
is  then  passed  with  clean  hands,  the  parts  being  fully  exposed  to  the  eye. 

Precautions  must  be  used  to  prevent  urine  from  trickling  over  the  wounded 
surfaces  or  into  the  vagina  as  the  instrument  is  withdrawn.  The  catheter, 
after  using,  should  be  cleansed  carefully  with  water.  Care  must  be  taken  that 
irritating  chemical  antiseptics  are  not  carried  into  the  urethra  upon  the  catheter; 
otherwise  a  troublesome  urethritis  may  result. 

2.  Management  of  Normal  Labor. 

Essential  to  the  proper  management  of  childbirth  is  a  watchful  super- 
vision of  the  health  and  habits  of  the  patient  throughout  pregnancy,  and  a 
previous  knowledge,  so  far  as  possible,  of  the  conditions  to  be  dealt  with  in 
each  case  during  labor.  Next  to  Listeriau  cleanliness,  nothing  is  destined  to 
do  more  for  improved  results  in  obstetrics  than  the  practice,  now  happily 
growing  with  obstetricians,  of  studying  their  cases  before  labor. 

It  is  desirable,  therefore,  that  the  pregnant  woman  be  under  the  observation 
of  her  phvsician  from  an  early  period  of  gestation,  and  especially  if  the 
experience  be  her  first.  Much-needed  information  and  advice  may  be  im- 
parted with  reference  to  the  hygienic  requirements  of  pregnancy.  Knowledge 
may  be  gained  of  conditions  likely  to  complicate  the  parturient  or  puerperal 
process,  and  much  may  often  be  done  to  fortify  the  health  and  strength  of 
the  patient. 

Dystocia,  if  it  cannot  be  prevented,  is  more  successfully  managed  with  the 
aid  derived  from  previous  knowledge  and  preparation.  Even  when  all  is 
normal,  both  patient  and  physician  are  amply  repaid  for  their  pains  by  the 
increased  confidence  with  which  the  result  of  labor  is  awaited. 

The  patient  should  be  advised  with  reference  to  the  selection  of  her  nurse. 
Instructions  will  be  needed  pertaining  to  the  care  of  the  nipples.  She 
should  be  directed  to  cleanse  them  daily  during  the  last  month  or  two  of 
pregnancy,  and,  if  they  are  very  small  or  sunken,  to  draw  them  out  with  the 
fingers.  This  manipulation  also  helps  to  inure  them  to  nursing.  Daily 
inunction  of  vaselin  or  of  fresh  cocoa-butter  during  the  same  period  keeps 
them  supple,  and  is  a  better  preparation  for  suckling  than  the  use  of  astrin- 
gents so  commonly  practised. 


THE   CONDUCT   OF  NORMAL   LABOR.  399 

Especially  important  is  it  that  the  functions  of  the  kidneys  be  watched. 
During  the  last  one  or  two  months  before  labor  the  urine  should  be  examined 
weekly.  Examinations  at  least  once  monthly  are  advisable  from  the  first. 
If  albumin  is  found,  the  microscopic  study  of  the  urine  will  best  reveal  the 
character  and  extent  of  the  structural  changes  in  the  kidneys.  In  general, 
the  best  evidence  of  the  manner  in  which  these  organs  are  performing 
their  functions  is  afforded  by  occasional  quantitative  tests  for  urea.  The 
patient  should  be  instructed  to  measure  the  urine  at  short  intervals  during 
the  later  months.  The  average  quantity  in  twenty-four  hours  should  not 
fall  short  of  3  pints.     The  specific  gravity  should  be  noted. 

Obstetric  Examination. 

In  the  later  months  it  is  the  duty  of  the  physician  to  make  a  preliminary 
obstetric  examination.  The  most  suitable  time  is  usually  about  the  end  of  the 
eighth  month.  The  object  is  to  determine  the  position  and  presentation  of  the 
child,  the  relative  size  of  head  and  pelvis,  and  the  possible  presence  of  patho- 
logical conditions  that  may  complicate  the  mechanism  of  labor.  It  is  to  be 
assumed  that  full  information  has  already  been  obtained,  at  the  time  of  engag- 
ing to  attend  the  patient  in  confinement,  with  reference  to  her  obstetric  history, 
including  the  number  of  previous  pregnancies,  term  labors,  and  miscarriages, 
all  important  facts  pertaining  to  the  character  of  the  pregnancies,  labors,  and 
childbed  periods,  and  particulars  relating  to  the  course  of  the  present  pregnancy. 

In  hospitals  it  is  the  rule  to  make  an  external  and  an  internal  examination. 
In  private  practice  an  internal  examination,  while  always  desirable,  need  not 
in  all  cases  be  insisted  upon.  Usually  all  that  is  necessary  to  know  may  be 
determined  by  the  external  methods.  In  the  presence  of  pelvic  deformity, 
and  in  all  cases  in  which  for  any  reason  the  external  examination  is  not  satis- 
factory, exploration  of  the  pelvic  cavity  should  not  be  omitted. 

It  is  essentia]  that  the  bladder  and  the  rectum  be  empty.  The  patient  lies 
upon  a  bed  or  a  lounge,  covered  with  a  sheet  and  with  the  limbs  outstretched. 
Her  clothing  is  to  be  loosened  and  the  skirts  drawn  above  the  abdomen.  The 
necessary  manipulations  are  conducted  under  the  sheet  or  through  it,  without 
exposure  of  the  patient.  In  this  manner  the  abdominal  examination  and  the 
external  measurements  of  the  pelvis  may  be  made  without  causing  discomfort 
or  giving  offense. 

The  hands  of  the  examiner  are  first  bathed  in  warm  water  to  render  the 
skin  soft  and  the  toucli  more  acute.  This  precaution,  too,  helps  to  prevent 
reflex  contractions  of  the  abdominal  and  the  uterine  muscles,  which  are  more 
likely  to  occur  when  the  hands  are  applied  cold  to  the  abdomen. 

The  examination  should  be  methodical.  Errors  of  diagnosis  are  more  fre- 
quently the  result  of  carelessness  than  of  ignorance.  Success  here,  as  in  most 
other  undertakings,  depends  upon  a  capacity  for  taking  pains.  All  manipula- 
tions are  to  be  conducted  gently,  and  need  never  cause  the  slightest  pain,  except 
rarely  when  deep  pressure  is  required  to  map  out  the  lower  fetal  pole.  A  defi- 
nite order  of  procedure  is  recommended  in  accordance  with  the  following  scheme : 


400 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


1.  Diagnosis  of  the  Fetal  Presentation  and  Position. 

Location  of  the  Dorsal  Plane  and  Small  Parts. — The  situation  of  the  dorsal 
plane  and  small  parts  of  the  fetus  may,  as  a  rule,  easily  be  made  out  by  palpat- 
ing the  abdomen.  The  palmar  surfaces  of  the  finger-tips  are  applied  with  light 
intermitting  touches  (Fig.  190).  Beginning  at  the  lower  part  of  the  abdomen,  a 
narrow  zone  is  palpated  entirely  across  from  one  side  of  the  tumor  to  the  other. 
The  palpation  is  repeated  over  a  similar  area  just  above  the  first,  and  so  on  until 
the  entire  surface  of  the  tumor  has  been  explored.  Usually  the  situation  of 
the  fetus  will  be  learned  by  the  first  touches.  It  presents  to  the  examining 
fingers  the  feel  of  a  solid  body,  while  elsewhere  over  the  tumor  only  fluid 
is  felt. 

The  location  of  the  child  may  more  readily  be  made  out  by  placing  one 
hand  flat  upon  the  middle  section  of  the  abdomen  and  pressing  firmly  back- 
ward (Fig.  191).  The  liquor  amnii  is  thus  displaced  to  one  side  and  the  child 
to  the  other,  where  it  can  more  easily  be  palpated. 


af  abdomen  for  locating  dorsal  plane  and 
photograph).1 


parts  of  fetus  (from 


The  child's  back  is  identified  by  the  length  and  breadth  of  the  resisting 
plane  which  is  offered  to  the  examining  touch,  and  by  the  absence  of  a  sulcus 
between  it  and  the  fetal  head.     The  side  of  the  child  presents  a  narrower 
1  The  photographs  for  this  article  were  made  by  Dr.  H.  F.  Jewett. 


THE    CONDUCT    OF  NORMAL    LABOR. 


401 


piane  than  the  back,  and  a  distinct  sulcus  separates  it  from  the  head.  The 
examination  of  the  dorsum  is  facilitated  by  applying  one  hand  over  the  upper 
fetal  pole  and  pressing  downward  in  the  axis  of  the  uterus.  The  back  of  the 
child  is  thus  rendered  more  convex,  and  is  thrust  outward  toward  the  abdomi- 
nal wall  within  easier  reach  of  the  examining  hand. 

The  small  parts  are  usually  felt  as  nodules  which  glide  about  under  the 
touch  :  they  are  best  identified  by  circular,  rubbing  motions ;  sometimes  a  fetal 
member  may  be  mapped  out  through  its  whole  extent.  Except  in  the  case  of 
twins,  where  there  are  usually  arms  and  legs  in  various  directions,  finding  the 
small  parts  in  one  section  of  the  abdomen  confirms  the  location  of  the  dorsal 
plane  in  the  opposite  region.  Thus,  small  parts  on  the  right  indicate  a  left 
dorsal  position,  and  conversely.     Small  parts  few  and  hard  to  find  point  to  an 


Fig.  191.— Depressing  abdominal  walls  in  locating  dorsal  plane  of  fetus  in  abdominal  examination  r 
displacing  child  to  that  side  of  the  uterus  toward  which  its  back  lies,  liquor  amnii  to  the  other  side 
(from  a  photograph). 


anterior  position  of  the  child's  back ;  small  parts  numerous  and  found  near 
the  middle  section  of  the  abdomen  usually  mean  a  dorso-posterior  position 
of  the  fetus. 

Examination  of  the  Lower  Fetal  Pole, — Facing  the  mother's  feet,  place  the 
hands  flat  upon  the  abdomen  over  the  lower  segment  of  the  uterus  (PI.  23). 


40:2  AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 

With    the    hands    resting    upon    the    sides    of    the    tumor,    their    palmar 


Fig.  192.— Locating  cephalic  prominence  by  palpation  with  both  hands.    The  hand  sinks  deeper  in  the 
pelvis  at  the  side  on  which  the  occiput  lies  (Leopold). 

surfaces  nearly   facing  each  other  and    the   finger-tips   1   or  2  inches  above 


Fig.  193. — Examination  of  upper  fetal  pole,  showing  relation  of  examining  hands  to  fetal  parts  (Leopold) 

the  level  of  the  pubes,  maintaining  firm  pressure,  the  finger-tips  are  gently 


CONDUCT  OP  NORMAL  LABOR. 


Examination  Befoee  Labor  :  Examination  of  lower  fetal  pole  (from  a  photograph). 


THE    CONDUCT    OF   NORMAL    LABOR,  403 

thrust  downward  into  the  brim  of  the  pelvis.  The  pelvic  excavation  is  then 
explored  to  learn  if  it  contains  the  presenting  fetal  part.  If  it  is  filled  before 
labor,  the  presenting  part  is  the  vertex.  No  other  fetal  part  sinks  into  the 
lesser  pelvis  until  labor  begins,  and  even  this  sinking  very  rarely  occurs  except 
in  primiparse.  In  the  latter  the  fetal  head  is  normally  always  in  the  pelvic 
brim.  During  labor  either  pole,  whether  the  woman  has  previously  borne 
children  or  not,  should  be  found  in  the  lesser  pelvis. 

The  head  when  it  lies  above  the  lesser  pelvis  is  not  usually  so  accessible  to 
palpation  as  when  in  the  excavation.  A  useful  maneuvre  for  locating  the 
head,  if  it  is  not  readily  found  by  direct  palpation,  is  to  place  the 
hands  in  the  usual  position  over  the  sides  of  the  lower  uterine  seg- 
ment and  proceed  as  for  external  ballottement,  bringing  the  hands  more 
and  more  nearly  together  until  the  head  is  found.  The  head  will  be 
recognized  as  a  solid  globular  body  which  can  be  tossed  from  one  hand 
to  the  other. 

The  cephalic  extremity  is  distinguished  from  the  breech  by  its  greater 
mobility  when  it  lies  above  the  excavation,  by  its  hardness  and  globular  shape, 
and  by  the  presence  of  a  sulcus  between  it  and  the  fetal  trunk.  The  breech 
alone,  is  smaller,  with  the  inferior  extremities  larger  than  the  head.  It  lacks 
the  hard  and  globular  character  of  the  head,  and  presents  no  sulcus  between 
itself  and  the  trunk.  An  imperfect  ballottement  of  the  head  is  frequently 
obtainable  when  it  lies  in  the  lower  segment  of  the  uterus  above  the  pelvic 
iulet. 

Cephalic  Prominence. — When  the  head  is  in  the  excavation  one  side  of  the 
brim  will  be  found  more  completely  filled  than  the  other  (Fig.  192).  This  is 
due  to  the  fact  that  the  occiput  sinks  deeper  into  the  pelvic  cavity  than  the  sinci- 
put. On  one  side  the  frontal  portion  of  the  head,  on  the  other  side  the  nape  of 
the  neck,  occupies  the  pelvic  brim.  That  side  of  the  cephalic  tumor  which  is 
the  more  prominent,  therefore,  is  the  sinciput.  Cephalic  prominence  to  the 
right  indicates  a  left,  to  the  left  indicates  a  right,  fetal  position.  The  situation 
of  the  greater  prominence  will  be  observed  in  the  course  of  the  palpation  above 
described.  It  may  also  be  made  out  by  arching  the  hand  across  the  abdo- 
men immediately  above  the  pubes  (PI.  24;  Fig.  196).  The  cephalic  promi- 
nence will  be  found  most  marked  in  oceipito- posterior  positions. 

Location  of  the  Anterior  Shoulder  in  Vertex  Presentation. — The  anterior 
shoulder  may  usually  be  found  as  follows :  While  the  hands  are  still  held 
upon  the  abdomen  over  the  sides  of  the  fetal  head,  move  them  upward 
toward  the  fundus  without  relaxing  the  pressure.  The  first  obstacle  they 
encounter  is  the  anterior  shoulder,  which  may  more  fully  be  identified  by  map- 
ping it  out  with  the  fingers  of  one  hand.  Steadying  the  fetal  mass  by  gentle 
pressure  with  the  other  hand  over  the  breech  facilitates  the  examination. 
Finding  the  anterior  shoulder  within  1  or  2  inches  of  the  median  line  indi- 
cates an  anterior,  and  several  inches  from  the  median  line  a  posterior,  position 
of  the  fetus.  In  left  positions  the  shoulder  lies  to  the  left,  in  right  positions 
to  the  right,  of  the  median  line  (Fig.  195). 


404 


AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 


Examination  of  the  Upper  Fetal  Pole. — The  examiner  next  faces  the 
mother's  face  and  places  his  hands  over  the  sides  of  the  fundus  (Figs. 
193,  194).  The  fundal  pole  of  the  fetus  is  then  examined  by  palpation. 
The    head    is    differentiated    from    the    breech    by    the    characters    already 


Fig.  194. — Examination  of  upper  fetal  pole  (from  a  photograph). 


mentioned  and  by  a  more  pronounced  ballottement  than  is  usually  pos- 
sible when  the  head  presents.  By  reason  of  its  smooth,  globular  shape, 
and  especially  of  its  flexible  attachment  to  the  trunk,  the  head  is  very 
movable,  rebounding  distinctly  under  the  touch  when  in  the  roomy  upper 
uterine  segment. 

Location  of  the  Fetal  Heart-tones. — The  stethoscope  may  or  may  not 
be  used,  according  to  the  usual  habit  of  the  examiner.  The  point  at 
which  to  listen  first  is  directly  over  the  supposed  location  of  the  upper 
part  of  the  child's  back.  Failing  here,  the  entire  surface  of  the  tumor 
may  be  searched. 

The  heart-sounds  are  usually  heard  over  an  area  of  about  3  inches  in 
diameter,  but,  since  they  are  sometimes  more  widely  diffused,  it  is  important 
to  locate  the  point  of  greatest  intensity.  The  point  upon  the  abdomen  at 
which  they  are  most  intense  is  termed  the  focus  of  auscultation.  As  a  rule, 
this  point  overlies  the  fetal  heart.     Exceptionally,  the  sounds  are  most  dis- 


CONDUCT  OF  NORMAL   LABOE. 


Examination  Before  Labor  :  Locating  the  cephalic  prominence  by  arching  the  hand  across  the  supra- 
pubic region  (from  a  photograph). 


THE    CONDUCT    OF  NORMAL    LABOR.  -405 

tinctly  heard  at  some  remote  point,  owing  to  firmer  contact  of  the  fetus  with 


Fig.  195.— Mapping  out  the  anterior  shoulder  (from  a  photograph). 

the  uterine  wall  at  that  point.     Their  location  usually  serves  to  distinguish 
left  from  right,  and  anterior  from  posterior,  positions.     In  a  posterior  posi- 


FiG.  196.— Method  of  locating  the  cephalic  prominence  by  arching  the  hand  across  the  suprapubic 

region. 


tion  the  heart,  if  heard  at  all,  is  found  far  back  over  one  side  of  the  abdo- 
men :  frequently  the  cardiac  sounds  are  quite  indistinct ;  rarely  they  are 
wholly  inaudible. 


406  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

For  the  diagnosis  of  presentation  the  situation  of  the  fetal  heart  is  of 
limited  value  in  women  who  have  borne  children.  Since  the  position  of  the 
heart  is  nearly  midway  between  the  extremities  of  the  fetal  ovoid,  the  mere 
inversion  of  the  long  axis  of  the  child  makes  little  difference  in  the  location 
of  the  heart-sounds.  In  primiparse,  in  whom  the  presenting  pole  sinks  into 
the  excavation  in  vertex,  and  rides  above  it  in  breech,  presentation,  the  level 
at  which  the  heart-tones  are  heard  is  of  some  value  in  determining  the  pres- 
entation. In  first  pregnancies  this  level  will  usually  be  found  below  the 
umbilicus  in  cephalic,  and  above  it  in  breech,  presentation. 

The  Location  of  the  Fetal  Movements  must  be  taken  on  the  statement  of 
the  mother,  which  statement  as  an  aid  to  diagnosis  is  liable  to  the  usual  fal- 
lacies of  subjective  signs.  It  may  have  some  weight,  however,  in  deciding  in 
what  part  of  the  uterus  the  feet  lie. 

Importance  of  the  Abdominal  Examination  for  the  Diagnosis  of  the  Fetal 
Presentation  and  Position. — With  all  the  facts  clearly  made  out  it  will  readily 
be  seen  that  the  abdominal  examination  is  of  more  value  for  the  diagnosis  of 
presentation  and  position  of  the  fetus  than  the  vaginal  touch.  Every  physi- 
cian, therefore,  should  familiarize  himself  with  the  technique  of  abdominal 
palpation  and  auscultation  in  its  application  to  obstetric  practice.  It  is  within 
the  power  of  every  obstetrician  to  become  expert  in  obstetric  diagnosis  by  the 
abdomen.  While  the  facilities  afforded  by  a  hospital  service  are  of  great 
advantage,  they  are  by  no  means  indispensable  if  proper  use  be  made  of  the 
opportunities  which  even  the  general  practitioner  has  at  his  command. 

Pathological  Conditions. 

After  determining  the  presentation  and  position  of  the  fetus,  the  abdomen 
is  next  to  be  examined  for  the  possible  existence  of  fetal  or  maternal  anom- 
alies that  may  complicate  the,  labor. 

A  pendulous  abdomen  in  a  first  pregnancy  should  suggest  the  possibility 
of  pelvic  deformity.  It  not  infrequently  occurs,  however,  in  multiparas  in 
whom  the  pelvis  is  normal,  and  it  may  retard  the  labor  by  hindering  the 
engagement  of  the  presenting  pole. 

Hydramnion  is  recognized  by  the  increased  size  and  permanent  tension  of 
the  uterine  tumor,  by  preternatural  mobility  of  the  fetus,  and  by  the  pres- 
ence usually  of  suprapubic  edema. 

The  entire  abdomen  is  explored  for  the  possible  presence  of  pathological 
growths  of  the  pelvic  or  abdominal  organs. 

Often  the  location  of  the  placenta  may  be  made  out  by  palpation  over 
the  abdomen,  except  when  its  implantation  is  mainly  upon  the  posterior  wall 
of  the  uterus.  Its  convex  edge  presents  a  resisting  ring,  and  the  palpation 
of  fetal  parts  is  partially  obscured  within  the  placental  area.  The  diagnosis 
of  vicious  insertion  of  the  placenta  is  therefore  sometimes  possible  by  abdomi- 
nal examination. 

A  hydrocephalic  head  of  a  size  sufficient  to  give  rise  to  difficulty  in  delivery 
ought  to  be  recognized  by  external  palpation.     Its  size  may  be  determined 


THE    CONDUCT   OF  NORMAL   LABOR. 


407 


more  accurately  by  measurements  taken  with  calipers  through  the  abdominal 
walls,  and  by  trying  whether  it  can  be  crowded  into  the  excavation. 

In  twin  pregnancies,  as  in  hydramnion,  the  abdominal  tumor  is  usually 
large  and  persistently  tense,  and  there  is  suprapubic  edema.  Indeed,  multiple 
pregnancies  are  generally  associated  with  excess  of  liquor  amnii.     Single  feta- 


Fig.  197.— Relative  location  of  the  posterior  superior  iliac  spines  and  spine  of  last  lumbar  vertebra.    The 
latter  is  the  second  vertebral  above  the  level  of  the  iliac  spines  (after  the  Ariadne). 

tion  with  hydramnion  is  distinguished  from  plural  pregnancy  by  the  greater 
mobility  of  the  fetus  in  the  former.  There  is  a  larger  number  of  small  parts 
in  plural  than  in  single  fetation,  and  they  are  more  widely  distributed.  Two 
dorsal  planes  and  more  than  two  fetal  poles  may  sometimes  be  made  out.  One 
head  in  the  excavation  and  one  in  the  upper  uterine  segment  or  in  one  iliac 
fossa  make  the  diagnosis  of  twins.  Two  fetal  poles  more  than  12  inches 
apart  cannot  belong  to  the  same  child.  The  most  conclusive  evidence  of 
double  fetation  is  the  detection  at  the  same  time  of  two  fetal  heart-beats  of 
different  rates. 

Palpation  in  multiple  pregnancy  is  generally  rendered  difficult  by  the  per- 
manent tension  of  the  uterine  tumor. 


2.  External  Measurements  of  the  Pelvis. 

In  primiparse,  and  in  multipara;  in  whom  the  previous  obstetric  history 
gives  rise  to  suspicion  of  pelvic  contraction,  the  external  diameters  of  the 


408 


AMERICAN   TEXT- BOOK    OF    OBSTETRICS 


pelvis  should  be  measured.  Three  measurements  are  usually  sufficient — 
namely,  the  external  conjugate,  the  interspinal,  and  the  intercristal. 

Of  these  measurements  the  most  important  is  the  external  conjugate  (PI. 
25).  This  diameter  is  measured  from  the  depression  (Fig.  197)  just  below 
the  spine  of  the  last  lumbar  vertebra  to  a  point  on  the  pubic  surface  in  front 
of  the  upper  part  of  the  symphysis.  It  may  safely  be  assumed  that  the 
pelvis  is  ample  when  this  diameter  exceeds  8  inches  (20.3  centimeters),  and 
that  it  is  contracted  at  the  brim  when  the  diameter  falls  below  that  limit, 
Q>\  inches  (about  16  centimeters).  Contraction  in  other  diameters  must  be 
excluded. 

An  interspinal  equal  to  or  greater  than  the  intercristal  diameter  indicates 
flattening  of  the  pelvis ;  when  both  are  small,  there  is  general  contraction. 

3.  Vaginal  Examixatiox. 

Before  examining  per  vaginam  the  obstetrician's  hands  and  the  external 
genitals  of  the  patient  are  to  be  cleansed  with  the  same  care  that  is  observed 
during  labor. 


Promontory 
Fig.  198. — Manual  method  of  measuring  the  diagonal  conjugate. 

In  parous  women  the  pelvic  floor  and  the  cervix  are  examined  for  injuries 
inflicted  during  previous  labors.  In  all  cases  the  diagonal  conjugate  and  the 
antero-posterior  and  bisischial  diameters  at  the  outlet  should  carefully  be 
measured  and  the  width  and  curvature  of  the  sacrum  be  noted.  The  method  of 
measuring  the  diagonal  conjugate  is  shown  in  Figure  198  and  Plate  26.  With 
the  patient  in  the  lithotomy  position,  two  fingers  of  the  examining  hand  are 


CONDUCT  OF  XORMAL   LAEOE. 


Elate  25. 


Measuring  the  external  conjugate:  the  black  dots  show  the  points  from  which  the  measurements 
are  taken  (from  a  photograph). 


CONDUCT   OF   NORMAL   LABOR. 


Plate  26. 


Manual  method  of  measuring  the  diagonal  conjugate :   p,  promontory ;  p,  B,  perineal  body  dis- 
placed backward. 


THE    CONDUCT   OF  NORMAL   LABOR.  409 

passed  into  the  vagina,  and  the  tip  of  the  second  finger  is  made  to  rest  by  its 
outer  margin  against  the  most  prominent  part  of  the  sacro- vertebral  angle. 
The  point  at  which  the  edge  of  the  subpubic  ligament  cuts  the  radial  border 
of  the  examining  hand  is  marked  by  a  finger-nail  with  the  other  hand.  The 
distance  between  the  points  of  contact  is  the  value  of  the  diagonal  conjugate. 
To  find  the  true  conjugate  the  amount  to  be  subtracted  from  the  diagonal  is 
usually  J. to  J  inch,  according  to  the  depth  and  inclination  of  the  symphysis. 
The  diameters  of  the  cavity  and  the  transverse  diameter  at  the  brim  are  esti- 
mated by  palpating  the  walls  of  the  pelvis. 

The  examining  hand  is  to  be  used  wet  with  the  antiseptic  solution.  If  any 
other  lubricant  is  required,  glycerin  or  vaselin  sterilized  by  heat,  or  glycerin 
biniodized  or  sublimated  (1  :  500),  may  be  employed. 

The  Lying-in  Room. 

In  private  practice  the  patient  is  generally  confined  in  the  room  which  she 
is  to  occupy  during  convalescence.  The  choice  of  room  is  not  a  matter  of 
indifference.  One  of  the  first  requisites  of  health  at  all  times  is  pure  air,  and 
this  should  not  be  denied  the  patient  at  a  time  when  the  need  of  oxygen  is 
greater  than  usual,  owing  to  the  severe  muscular  activity  of  labor  and  to  the 
increased  tissue-waste  of  the  puerperium.  If  possible,  therefore,  a  com- 
modious room,  one  which  permits  of  constant  ventilation,  should  be  selected. 
In  cold  weather  an  open  fire  is  an  efficient  aid  to  ventilation,  and  it  adds 
greatly  to  the  cheerfulness  of  the  lying-in  chamber. 

A  sunny  exposure  is  desirable.  Dust-laden  hangings  are  especially  objec- 
tionable, yet  it  is  neither  necessary  nor  best  to  so  far  dismantle  the  room  as  to 
make  it  cheerless.     Ordinary  cleanliness  is  usually  sufficient. 

On  no  condition  should  the  confinement  be  conducted  in  an  apartment 
recently  occupied  by.  a  patient  with  erysipelas,  childbed  fever,  suppurating 
wounds,  or  other  diseases  which  are  recognized  sources  of  possible  sepsis, 
except  after  systematic  cleansing  and  disinfection. 

The  management  of  the  patient  at  the  close  of  labor  is  simplified  if  a  sep- 
arate cot  be  provided  for  the  confinement,  tiie  patient  being  transferred  to  the 
bed  at  the  close  of  the  labor. 

The  Nurse's  Preparations. — An  orderly  nurse  will  have  ready,  conve- 
niently near  the  bed,  a  small  table  (Fig.  199)  properly  equipped  with  such 
appliances  as  the  doctor  will  need  for  use  during  the  labor.  The  table  should 
be  covered  neatly  with  one  or  two  sterilized  towels,  and  be  supplied  with  a 
wash-basin,  a  hand-brush,  soap  and  hot  water,  an  antiseptic  solution,  scissors, 
a  ligature  for  the  navel,  and  a  suitable  lubricant  for  the  hands.  The  utensils, 
the  ligature,  and  the  lubricant  should  be  sterilized. 

The  nurse  should  also  provide  plenty  of  aseptic  sheets  and  towels,  two 
dozen  sterilized  gauze  serviettes,  18  inches  square,  for  use  at  the  close 
of  labor  in  examining  or  suturing  pelvic  floor  injuries,  one  or  two  pieces  of 
unbleached  muslin  for  abdominal  binders,  a  half  yard  in  width  by  one  and  a 
quarter  yard  in   length,   one   or  two   surgically   clean   rubber  sheets   large 


410 


AMERICAN   TENT-BOOK    OF    OBSTETRICS. 


enough  to  cover  the  entire  width  of  the  bed,  plenty  of  muslin  sheets,  a  rug 
or  oil-cloth  to  protect  the  carpet  beside  the  bed,  safety-pins  of  convenient 
size  for  pinning  the  binder,  a  fountain  syringe,  a  suitable  bed-pan,  a  slop 
jar,  a  supply  of  hot  and  cold  water,  a  package  of  sterile  cotton  for  the  navel 
dressing,  a  blanket  for  wrapping  the  child,  and  the  child's  clothing.  Before 
sterilizing,  towels,  sheets,  serviettes,  etc.,  are  packed  in  small  bundles,  each 
enveloped  in  a  sheet  or  towel  securely  pinned.  Each  package  is  opened  only 
as  its  contents  are  required  for  use. 

Preparation  of  the  Bed. — The  patient  should  lie  upon  a  firm  mattress.  It 
is  customary  to  protect  the  bed  by  means  of  a  rubber  sheet,  which  should  be 
large  enough  to  cover  the  entire  width  of  the  bed  and  the  greater  part  of  its 


Fig.  199.— Table  equipped  with  basins,  brushes,  antiseptics,  etc.,  for  the  physician's  use. 


length.  Over  this  rubber  covering  is  spread  a  muslin  sheet,  the  two  cover- 
ings being  pinned  fast  to  the  mattress.  These  spreads  are  covered  with  a 
second  rubber  overlaid  with  a  bed-sheet.  The  latter  coverings  are  withdrawn 
after  labor,  leaving  the  bed  clean  and  protected  by  the  first  rubber  and  its 
muslin  covering.  Two  or  three  fresh-laundered  sheets,  each  folded  to  four 
thicknesses,  may  be  placed  upon  the  bed  in  position  to  receive  the  discharges. 

In  place  of  the  sheets  a  good  absorbent  dressing  is  a  pad  specially  made  for 
the  purpose.  It  consists  of  a  cheese-cloth  sack  or  bag,  which  is  filled  with 
jute,  absorbent  cotton,  cotton  waste,  or  other  absorbent  material  that  has  previ- 
ously been  prepared  and  sterilized.     The  sack  requires  to  be  from  1\  to  3  feet 


THE    CONDUCT    OF  NORMAL    LABOR. 


411 


square  and  3  or  4  inches  thick.  The  pad  is  best  sterilized  by  steaming  for 
an  hour  shortly  before  use.  If  a  separate  cot  is  used  for  the  confinement,  it 
is  to  be  equipped  in  the  manner  above  described. 

An  excellent  substitute  for  the  absorbent  pad  is  the  Kelly  rubber-pad,  now 
commonly  employed  in  gynecological  operations.  It  is  to  be  sterilized  before 
using. 

It  is  unnecessary  to  say  that  the  entire  dressing  of  the  bed  should  be  clean 
in  the  surgical  sense. 

Tlie  Patient. — The  patient  should  be  directed  to  receive  a  bath  at  the 
beginning  of  labor  and  to  make  an  entire  change  of  linen.  She  will  usually 
prefer  to  be  dressed  in  her  night-clothing,  over  which,  during  the  first  stage, 
she  may  wear  a  loose  wrapper.  A  napkin  or  a  pad  kept  wet  with  Thiersch's 
solution  and  worn  over  the  vulva  during  this  stage  is  a  useful  antiseptic 
measure. 

The  Obstetric  Bag. — It  is  recommended  that  the  obstetric  bag  be  large 
enough  to  contain  all  the  instruments  and  other  surgical  appliances  that  may 
be  needed  in  ordinary  labors.  The  equipment  should  comprise  obstetric  for- 
ceps ;  a  Davidson  syringe ;  a  hypodermic  syringe ;  a  glass  uterine  douche- 
tube  ;  a  soft-rubber  catheter ;  a  soft-rubber  tube  with  bulb  attached  for  aspi- 
rating mucus  from  the  child's  throat  in  case  of  asphyxia ;  a  half-dozen  needles, 


Fig.  200.— Schultze's  pelvimeter. 

about  2  inches  in  length  and  straight  or  slightly  curved,  for  suturing  the 
perineum ;  a  few  short  curved  needles,  an  inch  to  an  inch  and  a  quarter  in 
length,  for  use  in  the  vagina;  a  needle  forceps;  a  knife  for  episiotomy ;  steril- 
ized sutures  of  catgut,  silkworm-gut,  and  of  silk ;  one  or  two  hand-brushes ; 
a  yard  or  two  of  plain  aseptic  gauze  for  possible  use  in  post-partum  hemor- 
rhage ;  a  set  of  Barnes'  bags ;  and  a  Schultze  or  Collyer  pelvimeter  (Fig.  200). 
The  additional  instruments  that  will  frequently  be  of  service  are  a  Sims 
speculum,  one  or  two  sponge-holding  forceps,  a  volsella,  and  a  large  curette. 
A  small  spring-balance  will  be  useful  when  it  is  desirable  for  scientific  or 
other  reasons  to  know  the  weight  of  the  child. 


412  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

The  bag  should  also  be  supplied  with  two  or  three  ounces  of  chloroform, 
twice  as  much  ether,  a  few  ounces  of  carbolic  acid,  and  a  drachm  or  two  of 
chloral.  Mercurial  antiseptics  and  also  obstetric  emergents,  such  as  morphin, 
elaterin,  digitalis,  ergot,  and  veratrum  viride,  are  most  conveniently  carried  in 
tablet  form. 

4.  Anesthesia. 

Of  anesthesia  in  obstetrics  for  the  usual  surgical  indications  little  need  be 
said.  The  employment  of  anesthetics  in  obstetric  operations  is  governed  by 
the  well-established  usages  of  surgical  practice. 

By  obstetric  anesthesia  is  understood  something  entirely  distinct  and  apart 
from  surgical  anesthesia.  It  is  intended  to  diminish,  not  to  abolish,  pain. 
Its  object  is  merely  to  mitigate  the  severer  sufferings  of  ordinary  labor,  not 
to  cause  complete  insensibility. 

To  what  extent  anesthetic  agents  may  be  used  to  advantage  in  a  simple 
labor  is  a  question  that  calls  for  the  exercise  of  tact  and  judgment.  '  That,  on 
the  one  hand,  obstetric  analgesia  accomplishes  a  distinct  gain,  in  so  far  as  it 
spares  the  patient  the  exhausting  effects  of  severe  pain  and  prolonged  nervous 
tension,  cannot  be  doubted  ;  nor  has  the  obstetrician  any  more  pleasing  duty 
than  to  save  the  needless  sufferings  of  childbed.  On  the  other  hand,  except  in 
moderate  doses  and  during  the  most  active  period  of  labor,  anesthetics  are  lia- 
ble to  impede  the  progress  of  the  birth.  The  careless  and  long-continued  use 
of  these  agents,  especially  in  excessive  quantities,  is  fraught  with  serious  dan- 
ger to  the  patient.  Their  abuse  is  doubtless  at  times  an  unrecognized  factor 
in  grave  and  even  fatal  accidents  of  childbed.  These  objections  obtain  more 
especially  against  chloroform. 

With  reference  to  the  influence  of  anesthetics  upon  the  strength  and  the 
frequency  of  the  uterine  contractions  we  have  some  recent  observations  from 
Donhoff.1  He  administered  chloroform,  in  various  degrees,  to  five  parturients, 
studying  the  effect  upon  the  pains  with  the  aid  of  a  tokodynamometer.  Even 
under  small  doses  the  labor  was  retarded.  In  eight  observations  the  muscu- 
lar pressure  sank  nearly  to  one-half  that  present  before  the  administration, 
and  the  strength  of  the  uterine  contractions  was  not  fully  restored  for  several 
minutes  after  the  inhalations  were  stopped. 

That  the  use  of  anesthetics  during  labor  predisposes,  in  some  degree,  to 
relaxation  of  the  uterus  in  the  third  stage,  as  claimed  by  Lusk  and  others,  is 
abundantly  exemplified  in  the  writer's  experience. 

The  foregoing  facts,  while  they  do  not  forbid  the  employment  of  obstetric 
anesthesia,  call  for  the  exercise  of  caution  in  its  use.  When  required  for  no 
other  purpose  then  to  mitigate  the  sufferings  of  the  patient,  anesthetics  should 
be  reserved  until  the  latter  part  of  the  second  stage,  and  even  then  they  may 
be  withheld  so  long  as  the  pains  are  well  borne.  Their  employment  is  per- 
missible at  an   earlier  period  in   the   labor  when  required  to    subdue   great 

1  Archiv  fur  Gyn.,  Band  xlii,  12. 


THE   CONDUCT   OF  NORMAL   LABOR.  413 

nervousness  and  excitement  or  to  relieve  pains  of  extreme  and  unusual 
severity.  In  exceptional  cases  these  agents  may  act  to  accelerate  the  labor  by 
counteracting  the  inhibitory  effect  of  pain  upon  the  uterine  contractions. 

In  the  third  stage  of  labor  the  uses  of  anesthetics  are  chiefly  surgical. 
When  anesthesia  is  required  to  the  surgical  degree,  it  must  not  be  assumed 
that  the  obstetric  patient  enjoys  any  special  immunity  from  the  usual  dangers 
of  anesthetics.  The  relative  safety  of  obstetric  anesthesia  lies  not  in  any 
peculiarity  of  the  subject,  but  in  the  mode  of  administration,  the  limited 
dosage,  the  slow  and  gradual  inhalation,  and  the  intermittent  use  of  the 
drug,  during  the  pains  only.  Under  complete  anesthesia  the  parturient 
woman  is  exposed  to  the  same  dangers  as  are  other  patients. 

In  cases  in  which  an  operation  ordinarily  requiring  anesthetics  must  be 
performed,  neither  disease  of  the  heart,  of  the  lungs,  nor  of  the  kidneys,  nor 
the  exhaustion  of  the  third  stage  forbids  their  use.  These  conditions,  how- 
ever, necessitate  increased  caution  in  their  administration.  In  cardiac  dis- 
ease, even  in  lesions  of  the  myocardium,  anesthetics  lessen  the  danger  by 
subduing  the  reflexes. 

Choice  of  Anesthetics. — For  mere  obstetric  analgesia  chloroform  is  gen- 
erally preferred.  It  has  the  advantage  of  being  pleasanter  than  ether  and  is 
less  bulky  to  carry.  The  latter  agent  seems  to  be  growing  in  favor,  however, 
for  obstetric  use,  and  it  is  claimed  to  be  no  less  manageable  than  its  rival, 
chloroform,  for  partial  anesthesia.  Hirst  thinks  analgesia  is  even  more 
promptly  produced  by  ether  than  by  chloroform.  The  satisfactory  use  of 
ether  for  this  purpose,  however,  depends  upon  its  proper  administration.  It 
must  be  given  very  gradually  in  quantities  of  a  few  drops  with  each  inspira- 
tion. The  difference  in  the  safety  of  the  two  agents  is  insignificant  when  used 
in  the  obstetric  method. 

When  complete  insensibility  is  required  for  surgical  interference,  chloro- 
form should,  as  a  rule,  give  place  to  ether.  The  general  mortality  of  chloro- 
form when  pushed  to  the  surgical  degree  is  four  or  five  times  greater  than 
that  of  ether.  Of  the  two  agents,  chloroform  is  the  more  potent  and  its 
effects  persist  longer  after  inhalation  stops.  Ether,  since  it  is  used  in  larger 
quantities,  is  more  irritant  to  the  air-passages  than  is  chloroform ;  hence  the 
former  agent  should  be  replaced  by  chloroform  in  inflammation  of  the  air- 
passages,  especially  if  it  be  acute.  Ether  is  generally  believed  to  be  more 
dangerous  in  nephritis  than  is  chloroform,  but  this  question  is  not  fully  set- 
tled. Owing  to  the  tendency  of  the  former  agent  to  produce  high  arterial 
tension,  it  is  dangerous  in  marked  atheroma. 

Method  of  Administration. — The  patient  is  prepared  for  anesthesia  by 
loosening  the  clothing,  by  lowering  the  head,  and  by  attention  to  such  other 
precautions  as  are  commonly  observed  in  surgical  practice.  To  protect  the 
skin  from  the  irritating  effects  of  the  chloroform  vapor  the  lips,  nose,  and 
chin  may  be  smeared  with  vaselin  or  with  glycerin.  A  towel  spread  in  one 
thickness  over  the  head,  and  lifted  by  the  middle  six  or  seven  inches  so'  as  to 
form  a  large  air-chamber  about  the  face  (Fig.  201),  makes  a  suitable  inhaler. 


414 


AMERICAN   TEXT-BOOK    OF    OBSTETRICS, 


An  Esmarch  mask  is  also  a  convenient  apparatus  for  administering  the  anes- 
thetic in  the  lying-in  room. 

On  the  first  premonition  of  a  coming  pain  the  inhaler  is  placed  over  the 
face  of  the  patient,  and  the  anesthetic  is  dropped  upon  it  opposite  the 
month.  With  chloroform,  one  drop  or,  at  the  most,  2  drops  should  be  let 
fall  at  each  breath.  In  case  ether  is  used,  3  or  4  drops  with  each  inspiration 
will  suffice.  When  sufficient  effect  is  not  obtained  in  this  manner,  the  jjatient 
may  be  requested  to  breathe  rapidly  as  the  pain  is  coming  on. 

For  convenience  in  graduating  the  administration  a  bottle  specially  con- 
structed for  the  purpose  may  be  used,  or  a  dropping-bottle  may  be  improvised 
by  cutting  a  longitudinal  slot  in  the  side  of  the  stopper  (Fig.  201). 

The  foregoing  methods  of  administration  ensure  abundant  dilution  of  the 
anesthetic  vapors  with  air  and  a  safe  and  gradual  development  of  anesthesia 


Fig.  201— Method  of  i 


chloroform  with  the  towel  inhaler :  the  illustration  represents  the  towel  as 
transparent  (from  a  photograph). 


with  the  least  possible  quantity  of  the  drug.  The  inhaler  should  be  removed 
on  the  approach  of  unconsciousness,  and  should  always  be  withheld  in  the 
intervals  between  the  pains.  During  the  severer  pains  at  the  acme  of  ex- 
pulsion the  inhalation  may  usually  be  pushed  nearly  or  quite  to  the  surgical 
degree. 

Other  Anesthetic  Agents. — An  agent  of  great  value  as  a  partial  substitute 
for  the  anesthetic  vapors  is  chloral.  It  is  particularly  useful  for  alleviating 
the  pains  of  the  first  stage  when  they  are  not  well  borne.  From  45  to  60 
grains  may  be  given  in  doses  of  15  grains  repeated  every  twenty  minutes. 
The  total  quantity  should  not  exceed  a  drachm.      Under  the  full  close  the 


THE   CONDUCT   OF  N0B3IAL   LABOR.  415 

patient  usually  bears  the  pains  with  little  complaint,  and  sleeps  quietly  in  the 
intervals.  Chloral  in  the  quantity  mentioned  has  no  inhibitory  effect  upon 
the  uterine  contractions.  In  disease  of  the  heart,  either  organic  or  functional, 
the  wisdom  of  its  employment  is  questionable,  owing  to  its  depressant  effect. 
It  is  said  by  some  authorities  to  be  unsafe  to  give  chloroform  to  a  patient  who 
is  already  under  the  influence  of  chloral. 

The  coal-tar  analgesics  relieve  the  pains  of  labor,  but  they  also  tend 
to  cause  uterine  inertia. 

The  hydrochlorate  of  cocain  applied  to  the  cervix  and  vagina  has  proved 
of  little  service,  its  action  being  merely  superficial.  It  is  especially  objection- 
able on  the  ground  that  it  necessitates  interference  within  the  passages. 

From  an  eighth  to  a  quarter  grain  of  the  sulphate  of  morphin,  admin- 
istered hypodermatieally,  as  a  rule  acts  kindly  in  unusually  painful  labors,  but 
it  is  rarely  to  be  recommended  in  strictly  normal  conditions. 

Examination  during  the  Labor. 

The  first  duty  of  the  obstetrician  on  reaching  his  patient  in  response  to  her 
summons  is  to  satisfy  himself  that  she  is,  as  she  assumes,  actually  in  labor. 
The  beginning  pains,  however,  are  not  necessarily  to  be  taken  as  evidence  that 
active  labor  is  near  at  hand.  Painful  uterine  contractions  are  sometimes  expe- 
rienced at  intervals  for  days  before  the  birth.  Rarely,  after  they  are  fully 
established,  they  may  wholly  cease  for  hours. 

Inquiry  is  made  for  the  usual  phenomena  of  beginning  labor,  the  time  when 
the  pains  began,  and  their  character,  strength,  and  frequency.  Most  distinctive 
of  labor  is  the  rhythmical  character  of  the  pains  and  the  contraction  of  the 
uterus  during  the  pains  as  felt  by  the  hand  laid  upon  the  abdomen.  The  first 
uterine  contractions  of  childbirth  frequently  give  rise  to  little  more  than  a 
sense  of  pressure  in  the  sacral  and  the  lumbar  region.  As  the  labor  progresses 
they  are  felt  in  front  over  the  lower  abdomen,  and  finally  radiate  down  the 
thighs.  If  the  labor  is  in  actual  progress,  a  systematic  external  and  internal 
examination  is  to  be  made.  The  general  object  and  method  are  substantiallv 
the  same  as  in  the  preliminary  examination,  with  the  addition  of  certain 
details  which  pertain  especially  to  the  labor. 

The  abdominal  examination  aims  to  determine  whether  the  child  is  living, 
what  is  the  presentation  and  position,  the  quality  and  frequency  of  the  fetal 
pulse,  how  far  the  head  has  descended  in  the  pelvis,  the  presence  of  anomalies 
that  may  complicate  the  birth.  The  relative  size  of  the  head  and  pelvis  can 
be  estimated  by  observing  how  far  the  head  has  sunk  or  can  be  made  to  sink 
into  the  excavation.  In  doubtful  cases  measurements  of  the  head  may  be 
taken  with  calipers  through  the  abdominal  wall.  Distention  of  the  bladder 
is  recognized  by  palpation  over  the  suprapubic  region. 

The  diagnosis  of  presentation  and  position  by  abdominal  palpation  is  not 
usually  so  readily  made  at  this  time  as  before  labor,  but  in  most  cases  it  offers 
no  special  difficulty.  The  character  of  the  fetal  heart-sounds  affords  im- 
portant information  as  to  the  prognosis  for  the  child,  and  they  should  fre- 


416  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

quently  be  listened  to  throughout  labor.  A  fetal  pulse-rate  much  above  or 
below  the  normal  range,  or  a  pulse  which  grows  progressively  weaker,  indi- 
cates danger  to  the  child. 

When  a  systematic  preliminary  examination  has  been  made,  little  additional 
information  remains  to  be  gained  by  examining  internally  after  labor  begins. 

For  the  detection  of  possible  complications  that  may  have  developed  at 
the  onset  of  labor,  such  as  prolapse  of  the  cord  or  of  a  fetal  member,  as  well 
as  for  more  precise  information  of  the  stage  of  progress,  a  vaginal  examination 
is  usually  desirable,  even  though  the  obstetrician  be  expert  in  abdominal 
palpation. 

Before  examining  internally  the  nurse  is  directed  to  cleanse  the  abdomen, 
the  vulva,  and  the  inner  surfaces  of  the  thighs  with  soap  and  water,  and 
finally  with  an  antiseptic  solution  ;  meantime  the  obstetrician  prepares  his 
hands  and  forearms. 

The  object  of  this  examination  is  to  learn — (1),  the  condition  of  the  vulva 
and  the  degree  of  resistance  it  will  be  likely  to  offer  as  the  head  descends;  (2), 
whether  the  vagina  is  well  lubricated  by  the  secretions,  and  the  presence  or  ab- 
sence of  obstruction  ;  (3),  the  condition  of  the  cervix,  how  far  dilated,  whether 
dilatable  as  judged  by  the  extent  of  softening  and  thinning;  (4),  the  size  and 
protrusion  of  the  bag  of  waters ;  and  (5),  the  presentation  and  position  of  the 
child  in  confirmation  of  the  abdominal  examination. 

Vertex  presentations  are  recognized  by  the  hardness  and  the  globular 
shape  of  the  cranial  portion  of  the  head  and  by  tracing  the  sutures  and 
fontanelles.  As  the  anatomical  characters  of  the  presenting  part  are  often 
somewhat  obscured  by  the  caput  succedaneum,  the  examination  must  be  made 
with  care,  using  firm  pressure  and  searching  as  far  as  the  fingers  can  reach. 
In  other  than  vertex  presentations  still  greater  pains  will  generally  be  needed 
to  identify  the  presenting  prfrt.  During  the  vaginal  examination  the  hardness 
of  the  child's  head  should  be  taken  into  account  as  an  important  element  in 
the  prognosis.  The  position  is  determined  by  finding  in  which  quadrant  of 
the  pelvis  the  small  fontanelle  lies.  This  is  best  located  by  first  tracing  the 
sagittal  suture.  (For  diagnostic  signs  of  other  than  vertex  presentation  the 
reader  is  referred  to  the  chapter  treating  of  those  presentations.) 

The  examiner  will  learn  whether  the  membranes  are  still  intact,  and  how 
far  they  protrude  during  a  pain,  and  will  make  sure  that  a  loop  of  the  cord 
has  not  prolapsed  into  the  bag  of  waters.  It  is  perhaps  unnecessary  to  say 
that  in  this  part  of  the  examination  care  will  be  needed  lest  the  membranes  be 
prematurely  ruptured. 

To  the  question  which  is  invariably  asked,  "  How  long  will  the  labor  last?'' 
a  guarded  answer  must  be  given.  Definite  predictions  are  seldom  possible  at 
the  beginning  of  labor.  The  prognosis,  so  far  as  it  can  be  estimated,  must  be 
based  on  the  capacity  of  the  pelvis,  the  strength  and  the  frequency  of  the 
pains,  the  extent  of  dilatation  and  the  dilatability  of  the  cervix,  the  position, 
size,  and  hardness  of  the  head,  and  the  degree  of  descent.  When  nothing 
abnormal  has  been  discovered,  assurance  should  be  given  accordingly. 


THE    CONDUCT   OF  NORMAL   LAB  OH.  417 

Management  op  the  First  Stage. 

During  the  first  stage  of  labor  the  patient  ought  not,  as  a  rule,  to  be  con- 
fined to  the  bed  until  dilatation  is  well  advanced.  She  is  usually  more  com- 
fortable if  allowed  the  liberty  of  the  room,  and  the  pains  are  thereby  pro- 
moted. Much  walking  is  not  advisable,  however,  before  the  head  has  engaged  ; 
it  may  favor  prolapse  of  the  cord  or  of  the  small  parts,  and  may  hinder  engage- 
ment. If  the  membranes  rupture  or  if  the  pains  assume  unusual  intensity,  the 
patient  must  be  kept  in  a  reclining  posture  upon  the  bed  or  a  lounge. 

Malpositions  are  often  capable  of  correction  by  postural  methods,  the 
woman  being  required  to  lie  upon  the  side  toward  which  that  part  of  the 
head  points  that  is  to  lead  the  descent.  For  example,  in  a  right  occipito- 
posterior  position  the  patient  should  lie  upon  the  right  side,  and  in  a  left  pos- 
terior position  of  the  occiput  upon  the  left  side. 

The  clothing  should  be  loose,  and  be  limited  to  a  wrapper  and  the  under- 
clothing. 

If  the  physician  in  his  first  examination  has  satisfied  himself  of  the 
absence  of  complications,  the  vaginal  examination  will  rarely  need  to  be 
repeated  until  after  the  rupture  of  the  membranes.  When  the  protruding 
bag  breaks  before  the  head  is  engaged,  it  is  well  to  make  sure  that  a  loop  of 
the  cord  has  not  been  swept  down  with  the  gush  of  waters.  If  the  first  stage 
is  unduly  retarded,  a  careful  digital  exploration  by  the  vagina  may  be  needed 
to  learn  the  cause  of  delay. 

The  physician's  first  visit  should  be  prolonged  sufficiently  to  form  some 
estimate  of  the  probable  rapidity  of  the  labor  and  of  the  length  of  time 
before  his  attendance  will  again  be  required.  On  departing  all  needed 
instructions  should  be  left  with  the  nurse.  The  patient  is  to  be  allowed 
such  food  and  drink  as  may  be  necessary,  to  be  warned  against  voluntary 
expulsive  efforts,  and  is  usually  to  remain  out  of  bed  until  the  pains  are 
severe.  The  lower  bowel  should  be  cleared  and  the  bladder  frequently 
evacuated. 

During  this  stage  it  is  a  general  rule  for  the  physician  not  to  remain  with 
the  patient  until  the  os  has  reached  the  size  of  a  silver  dollar.  Even  after  his 
continuous  presence  at  the  house  is  required,  he  will  better,  in  most  cases,  absent 
himself  from  the  room,  except  when  his  attentions  are  needed  by  the  patient. 

Throughout  the  labor  idle  bystanders  should,  as  a  rule,  be  excluded  from 
the  lying-in  chamber.  The  presence  of  the  husband  is  a  matter  to  be  left  to 
himself  and  the  patient. 

Both  the  maternal  and  the  fetal  pulse  should  occasionally  be  counted. 

All  manipulations  within  the  passages  for  the  purpose  of  accelerating  the 
labor  in  normal  cases  are  scrupulously  to  be  avoided. 

Rarely  when  the  anterior  lip  of  the  cervix  is  caught  over  the  occiput,  and 
apparently  retards  the  progress  of  the  labor,  it  may  be  hooked  forward  during 
a  pain  until  it  retracts  above  the  head.  This  is  a  practice,  however,  that  is 
very  liable  to  abuse. 


418  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

Management  op  the  Second  Stage. 

In  the  second  stage  of  labor,  as  in  the  first,  so  long  as  all  is  normal 
the  duties  of  the  obstetrician  are  few  and  simple.  From  the  time  dila- 
tation is  nearly  complete  the  patient  must  not,  as  a  rule,  be  allowed  to 
leave  her  bed,  not  even  for  evacuations  of  the  bladder  or  the  bowels.  She 
is  to  be  dressed  in  the  usual  night-clothing,  which  the  nurse  will  keep  well 
tucked  under  the  arms,  beyond  the  reach  of  soiling.  A  folded  sheet  hung 
like  a  skirt  from  the  hips  still  further  conduces  to  cleanliness.  When  the 
pains  are  feeble,  their  intensity  may  be  increased  by  requiring  the  patient 
to  move  about  in  bed  or  even  to  assume  for  a  time  a  sitting  or  a  half-sitting 
posture.  The  uterine  expulsive  efforts  should  be  reinforced  by  the  voluntary 
muscles.    Direct  the  patient  to  "  hold  the  breath  and  bear  down  with  the  pains." 

Most  women  during  the  expulsive  pains  instinctively  brace  their  feet  and 
catch  the  hands  of  the  nearest  bystander  to  assist  the  straining  effort  by  pull- 
ing. Except  in  precipitate  labor  this  practice  is  to  be  encouraged.  A  sheet 
rolled  into  a  loose  rope  and  fastened  by  one  end  to  the  foot  of  the  bed  makes 
a  convenient  and  efficient  sling  for  the  purpose. 

An  abdominal  binder  is  frequently  useful  in  helping  the  progress  of  labor 
during  the  second  stage,  particularly  in  multipara?  having  lax  abdominal  walls. 

The  distressing  sacral  pains  so  common  in  the  expulsive  stage  of  labor  may 
be  relieved  in  some  degree  by  pressure  over  the  painful  region.  For  this  pur- 
pose the  nurse,  taking  position  on  the  bed  behind  the  patient  as  she  lies  upon 
the  side,  supports  the  back  by  pressing  firmly  against  the  sacrum  with  the 
palms  of  the  hands  during  the  pains. 

Cramps  in  the  lower  limbs  are  best  overcome  by  powerfully  contracting  the 
antagonistic  muscles.  In  case  of  cramps  in  the  calf  of  the  leg,  for  example, 
the  patient  should  forcibly  flex  the  foot  and  hold  it  so  until  the  muscular  spasm 
subsides. 

Rupture  of  the  Membranes. — When  the  bag  of  membranes  does  not  burst 
spontaneously  by  the  time  it  reaches  the  pelvic  floor,  it  should  be  ruptured  by 
the  obstetrician.  Care  must  first  be  taken  to  see  that  a  loop  of  the  cord  has  not 
slipped  down  beside  the  head,  as  that  condition  of  things  would  seriously  be 
complicated  by  the  escape  of  the  waters.  It  is  not  usually  difficult  to  tear 
the  sac  with  the  finger-nail  during  a  pain.  Failing  by  this  method,  a  sharp- 
pointed  scissors,  previously  sterilized,  may  be  used.  A  convenient  instrument 
for  the  purpose,  generally  to  be  found  in  the  lying-in  room,  is  a  coarse  hairpin. 
It  is  first  straightened  and  then  well  flamed.  This  perforator  is  passed  on  the 
finger-tip  as  a  guard  and  a  guide,  and  the  bag  of  membrane  is  punctured  while 
tense  during  a  pain. 

Obstetric  Position. — As  a  rule,  the  posture  of  the  patient  should  be  left 
largely  to  her  own  choice.  Occasional  changes  relieve  fatigue.  In  simple 
slow  labor  the  pains  are  promoted  by  permitting  her  to  move  about  in 
bed  and  now  and  then  to  take  a  sitting  position.  Until  the  head  reaches 
the    pelvic   floor   a   half-sitting    posture    is    the    most    favorable,    since    the 


THE   CONDUCT   OF  NORMAL   LABOR.  419 

propelling  force  thus  acts  most  effectively  in  the  Hue  of  descent.  At  the 
perineal  stage  the  lateral  position  with  the  body  flexed,  which  position  is 
most  advantageous  for  the  obstetrician,  is  at  the  same  time  advisable  from  the 
standpoint  of  the  mechanism.  The  lower  end  of  the  sacrum  is  tilted  back- 
ward, and  some  advantage,  perhaps,  may  be  derived  from  the  fact  that  gravity 
acts  more  nearly  in  the  axis  of  expulsiou. 

Frequency  of  Vaginal  Examination. — Vaginal  examinations  should  be  as 
infrequent  as  possible.  There  is  seldom  occasion  in  normal  conditions  for 
more  than  one  or  two  internal  examinations,  at  the  most,  during  the  expulsive 
stage.  The  descent  of  the  head  may  be  followed  by  palpating  over  the  lower 
abdomen  until  the  occiput  has  reached  the  floor  of  the  pelvis.  From  that 
time  the  progress  of  the  descent  may  be  noted  by  the  touch  through  the 
pelvic  floor,  and  during  the  last  moments  of  expulsion  by  ocular  inspec- 
tion. 

All  that  the  obstetrician  needs  to  know  in  normal  cases  can  usually  be 
learned  by  abdominal  palpation  and  auscultation.  Frequent  vaginal  exam- 
inations expose  the  patient  to  possible  infection  despite  all  other  care  in 
the  matter  of  subjective  asepsis.  Particularly  is  this  the  case  when  the 
manipulation  extends  into  the  lower  uterine  segment. 

Prevention  of  Injuries  to  the  Pelvic  Floor. — The  frequency  of  pelvic-floor 
lacerations  in  term  deliveries  in  general  practice  may  fairly  be  estimated  at 
about  35  per  cent,  in  first,  and  10  per  cent,  in  subsequent,  labors.  In  little 
less  than  half  this  number  the  injury  must  be  regarded  as  unavoidable,  except 
by  substituting  incisions. 

In  strictly  normal  conditions  the  muscular  structures  of  the  pelvic  floor 
relax  slowly  under  the  pressure  of  the  gradually  advancing  head  and  escape 
intact.  The  fourchette,  however,  is  frequently  torn  in  first  births.  In 
relatively  small  vulvovaginal  outlets  and  in  rigidity  of  the  structures 
from  whatever  cause  the  parts  will  generally  be  lacerated  during  the 
expulsion  of  the  head,  notwithstanding  the  most  skilful  efforts  of  the 
obstetrician. 

The  order  in  which  the  tissues  give  way  is  fascia,  muscle,  mucous  mem- 
brane, skin.  Accordingly,  a  laceration  may  occur  subcutaneously,  the  tear 
being  confined  to  the  muscles  and  fascia  and  no  breach  of  continuity  appear- 
ing to  the  eye. 

Numerous  procedures  have  been  proposed  for  the  prevention  of  perineal 
injuries  during  delivery.  The  discussion  in  this  place  of  the  various  methods 
that  have  been  upheld  by  obstetric  writers  would  serve  no  useful  purpose. 
Most  of  them  must  be  regarded  as  irrational  and  useless,  if  not  even  mis- 
chievous. 

When  we  reflect  that  the  cause  of  the  tear  is  undue  strain  upon  the 
resisting  girdle  through  which  the  head  passes  at  the  moment  of  expulsion,  it 
is  plain  that  any  measure  to  be  of  value  in  preventing  the  injuries  in  question 
must  do  one  or  both  of  two  things  :  It  must  act  to  promote  the  relaxation 


|-,l 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


and  extensibility  of  the  pelvic  floor,  or  to  lessen  the  tension  to  which  it  is 
subjected  during  the  birth,  or  both.  The  former  object  is  best  accomplished 
by  the  slow  and  gradual  delivery  of  the  head,  permitting  time  for  the  tissues 
to  stretch ;  the  latter,  by  so  regulating  the  expulsion  of  the  head  as  to  keep 
its  smallest  circumference  in  the  grasp  of  the  resisting  girdle  and  the  propel- 
ling power  directed  in  the  axis  of  the  outlet. 

The  rate  of  descent  is   perfectly  at  command   of  the  obstetrician.     The 


expulsive  force  of  the  abdominal  muscles  may  sometimes  be  suspended  by 
requiring  the  patient  to  breathe  rapidly  during  the  pains.  This,  however,  is 
not  always  possible.  The  action  of  the  abdominal  muscles  is  at  this  stage 
frequently  involuntary  and  wholly  beyond  the  patient's  control.     Most  effect- 


THE    CONDUCT   OF  NORMAL    LABOR.  421 

nal  for  the  regulation  of  the  expelling  powers  is  the  use  of  anesthetics. 
Chloroform  or  ether  should  be  given  at  this  period  on  the  appearance  of  the 
slightest  danger  of  laceration.  By  the  judicious  use  of  the  anesthetic  the 
strength  and  frequency  of  the  pains  and  the  rapidity  of  expulsion  may  be 
regulated  at  will. 

The  advance  of  the  head,  however,  can  still  further  be  controlled  by  pres- 
sure with  the  thumb  and  finger  held  constantly  upon  the  occiput.  With  the 
thumb  applied  to  the  head  immediately  in  front  of  the  tense  border  of  the 
perineum,  and  with  two  fingers  resting  upon  the  occiput,  the  rate  of  descent 
may  easily  be  watched  and  regulated. 

To  keep  the  tension  of  the  vulva  at  a  minimum,  the  long  axis  of  the 
cephalic  cylinder  must  be  kept  at  a  right  angle  with  the  plane  of  the  outlet 
of  the  soft  parts  Too  rapid  extension  of  the  head  must  be  prevented.  The 
forehead  should  not  be  permitted  to  pass  the  perineum  until  the  occiput  is 
fully  expelled  and  the  nape  of  the  neck  rests  in  the  subpubic  arch. 

Moreover,  to  guard  against  too  great  strain  upon  the  pelvic  floor,  the 
direction  of  expulsion  must  be  regulated  by  crowding  the  head  well  up  in  the 
pubic  arch,  especially  at  the  time  when  the  equator  of  the  head  passes  the 
vulvar  ring.  The  expelling  force  is  thus  directed  in  the  axis  of  the  outlet, 
and  the  least  possible  downward  thrust  is  exerted  upon  the  pelvic  floor. 

The  foregoing  manipulations  are  best  conducted  with  the  patient  in  the 
left  lateral  position.  In  first  labors,  therefore,  and  in  others  in  which  the 
perineum  is  liable  to  be  torn,  the  patient  should,  as  a  rule,  be  placed  upon  the 
left  side,  with  the  buttocks  close  to  the  edge  of  the  bed,  as  soon  as  the  head 
has  reached  the  floor  of  the  pelvis.  There  is  rarely  danger  of  laceration  until 
after  the  occipital  pole  appears  in  the  vulvar  fissure.  Up  to  this  point  usually 
the  progress  of  the  perineal  stage,  when  not  over-rapid,  may  be  noted  by  the 
touch  alone.  With  the  finger  upon  the  perineum  just  behind  the  posterior 
vulvar  commissure  the  occiput  can  be  felt  through  the  soft  parts  some  time 
before  it  begins  to  distend  the  perineum,  and  the  rate  of  descent  can  be 
observed  as  accurately  as  by  passing  the  finger  within  the  passages. 

From  the  moment  the  occiput  appears  in  the  vulvar  orifice  the  parts  ought 
to  be  under  ocular  inspection.  The  vaginal  discharges  are  occasionally  washed 
away  with  a  cloth  which  is  kept  lying  in  a  warm  antiseptic  solution.  The 
tension  of  the  resisting  ring  may  be  tested  by  now  and  then  passing  the 
finger  within  the  vaginal  orifice  during  a  pain.  The 
head  is  allowed  to  advance  during  a  pain  until  the 
perineal  edge  becomes  as  tense  as  is  deemed  safe.  Its 
further  progress  is  then  arrested  by  direct  pressure  with 
the  fingers  in  the  line  of  descent  (Fia;.  203\   Until  about        FiG.203- 

.  '  pulsion  of  the  head  with 

to  be  expelled,  driven,  down  with  the  pains,  it  recedes    the  fingers  of  one  hand 
in  the  intervals,  and  by  this  to-and-fro  movement  the    asainst  the  occiput- 
pelvic  floor  is  moulded  as  it  were  to  the  required  degree  of  distention. 

When  the  bregma  appears  at  the  edge  of  the  perineum,  the  head  no  longer 
recedes   between   the  pains  and  is  on   the  verge  of  expulsion.     During  the 


422 


AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 


passage  of  the  equator  of  the  head  extension  must  be  prevented  by  upward 
pressure  in  the  axis  of  expulsion  with  the  thumb  placed  upon  the  sinciput 
close  to  the  perineum,  the  fingers  resting  upon  the  occiput.  The  sinciput 
must  not  be  permitted  to  advance  faster  than  the  occiput.  If  required  for 
the  better  control,  both  hands  may  be  used  (Fig.  204). 

A  favorite  method  for  managing  the  expulsion  of  the  head  is  the  fol- 
lowing :  The  patient  lying  upon  the  left  side  close  to  the  edge  of  the  bed, 
the  operator,  sitting  behind  her,  grasps  the  head  with  the  fingers  of  the 
right  hand  placed  just  in  front  of  the  fourchette,  while  the  left  hand,  passed 
over  the  abdomen  and  between  the  thighs  of  the  mother,  seizes  the  occiput 


(Fig.  202).  This  procedure  gives  easy  command  of  the  birth  of  the  head, 
yet  oifers  no  important  advantage  over  simpler  methods.  The  writer  prefers 
to  this  the  manipulation  shown  in  Figure  204. 

As  a  rule,  in  first  labors  a  half  hour  or  more  from  the  time  the  pelvic 
floor  begins  to  be  distended  will  be  required  before  the  head  can  safely  be 
allowed  to  pass.     In  subsequent  births  a  shorter  time  will  usually  suffice. 

While  the  procedures  just  described  are  to  be  recommended  to  the  general 
exclusion  of  other  methods,  there  is  no  objection  to  the  use  of  gentle  pressure 


THE    CONDUCT  OF  NORMAL   LABOR.  423 

applied  to  the  head  through  the  lateral  aspects  of  the  pelvic  floor.  For  this 
purpose  the  hand  may  be  laid  flat  upon  the  bulging  soft  parts  with  the  thumb 
extending  aloDg  the  right,  and  the  fingers  parallel  with  the  left,  labium.  The 
hand  should  rest  lightly  upon  the  median  thinned-out  portion  of  the  perineum, 
the  pressure  being  applied  mainly  to  each  side  of  it.  It  must  be  borne  in 
mind,  however,  that  the  object  is  to  regulate  the  expulsion  of  the  head,  not  to 
support  the  perineum.  Much  compression  of  the  tense  pelvic  floor,  especially 
its  thinned-out  median  portion,  between  the  child's  head  and  the  obstetrician's 
hand,  must  tend  rather  to  increase  than  to  diminish  the  danger  of  rupture. 
If  the  patient  lies  upon  the  back  during  the  perineal  stage,  it  will  be  found 
more  convenient  to  regulate  the  expulsion  by  the  thumb  placed  upon  the  occi- 
put and  the  first  two  fingers  upon  the  head  in  front  of  the  frenulum. 

The  introduction  of  the  finger  into  the  rectum  for  the  purpose  of  shelling 
out  the  head,  even  when  practised  between  the  pains,  is  more  likely,  as  a  rule, 
to  cause  than  to  prevent  laceration  by  too  precipitate  delivery. 

It  is  difficult  to  understand  how  the  tendency  to  rupture  can  be  diminished 
by  drawing  the  perineum  forward  with  the  finger  in  the  rectum,  as  advised  by 
Goodell.  As  Garrigues  has  pointed  out,  an  elastic  ring  encircling  a  cylinder 
is  subjected  to  less  tension  when  at  a  right  angle  to  the  cylinder  than  when 
oblique.  Moreover,  interference  within  the  rectum,  however  practised,  is 
hardly  consistent  with  the  requirements  of  aseptic  obstetrics. 

Episiotomy. — No  method  yields  better  results  for  the  ultimate  integrity 
of  the  perineum  than  episiotomy  rightly  timed  and  properly  executed.  The 
ultimate  condition  of  the  pelvic  floor  after  episiotomy  correctly  performed  is 
even  better  than  after  many  natural  deliveries  in  which  the  parts  escape  rup- 
ture. The  tonicity  of  the  structures  frequently  remains  as  perfect  as  in  the 
non-parous  woman. 

The  success  of  the  incisions  in  preventing  laceration  depends,  as  already 
intimated,  upon  so  timing  them  as  wholly  to  anticipate  the  tearing,  and  upon 
carefully  adjusting  the  location  and  direction  of  the  cuts.  This  apparently 
simple  procedure,  therefore,  is  one  in  which  even  the  accomplished  obstetrician 
may  find  room  for  the  exercise  of  skill. 

The  only  instrument  required,  in  addition  to  what  is  carried  in  the  usual 
obstetric  outfit,  is  a  blunt-pointed  tenotomy  knife.  When  laceration  seems 
inevitable  or  even  probable,  the  cordlike  ring,  which  can  be  felt  about  half  an 
inch  above  the  tense  border  of  the  vulva  by  examination  during  a  pain,  should 
be  divided.  Locating  the  resisting  girdle  by  the  finger,  the  knife  is  passed 
flatwise  between  the  head  and  the  vaginal  wall.  The  edge  of  the  knife  is 
then  turned  outward  and  the  ring  incised.  The  operation  is  repeated  on  the 
opposite  side.  The  length  of  the  incision  should  be  about  one  inch,  its  depth 
a  quarter-inch,  and  its  location  about  one-third  way  from  the  posterior  to 
the  anterior  commissure  when  the  parts  are  on  the  stretch.  The  structures 
involved  in  the  incision  when  made  in  this  manner  are  unimportant. 
They  consist  usually  of  the  skin,  fascia,  and  probably  the  bulbo-cavernous 
muscle. 


424 


AMERICAN  TEXT-BOOK  OF  OBSTETRICS. 


Most  essential  is  it  that  the  cuts  be  made  parallel  with  the  long  axis  of  the 
mother's  body,  not  with  the  vaginal  axis.  The  cuts  will  then  be  found  on 
examination  after  labor  to  run  parallel  with  the  outlet  of  the  birth-canal.     If 

the  knife  be  held  in  line  with  the  axis 
of  the  vulvo-vaginal  outlet  as  the  latter 
appears  at  the  time  of  incision,  its  point 
will  be  liable  to  invade  the  very  struc- 
tures the  operation  aims  to  save ;  the  pos- 
terior ends  of  the  incisions  will  be  found 
after  delivery  much  nearer  the  median 
line  than  was  intended,  and  the  trans- 
versus  perinei  and  other  important  struc- 
tures will  possibly  be  divided.  This 
result  is  well  shown  in  the  accompany- 
ing illustrations  by  Dr.  R.  L.  Dickin- 
son '  (Figs.  205,  206). 

If  preferred,  the  resisting  ring  may 
be  divided  with  scissors.  After  labor 
the  cuts  should  immediately  be  reuuited 
with  stitches.  A  running  or  an  inter- 
rupted suture  with  fine  catgut  best  an- 
swers the  purpose.  The  wounds  may 
.y  (sketch,  just  after  be  closed  generally  without  waiting  for 
the  delivery  of  the  placenta,  thus 
saving  the  necessity  for  renewing  the 
anesthesia.  During  the  suturiug  the 
patient  may  lie  on  the  back  or  on  the 
side    opposite    the    one    being    repaired. 

Management  of  the  Cord. — The  moment  the  head  is  born  a  finger  is  slipped 
within  the  passages  to  ascertain  if  the  cord  is  coiled  about  the  child's  neck. 
When  so  found,  the  loop  or  loops  should  be  drawn  down  one  by  one  over  the 
head.  Should  the  coil  be  so  taut  that  it  cannot  be  brought  down— an  accident 
that  must  be  extremely  rare— the  cord  may  be  tied  at  two  points,  and  be  cut 
between  the  two  ligatures  and  the  trunk  promptly  delivered. 

Delivery  of  the  Trunk. — The  head  should  now  be  held  in  the  hand  to  keep 
it  in  the  axis  of  expulsion.  Contrary  to  the  usual  teaching,  the  writer  prefers 
to  deliver  the  posterior  shoulder  first.  While  the  anterior  shoulder  lies  behind 
the  symphysis  the  finger  is  passed  over  the  dorsal  aspect  of  the  posterior  shoul- 
der and  is  slipped  into  the  axilla.  The  posterior  shoulder  is  then  folded  for- 
ward and  is  cautiously  lifted  over  the  perineum. 

Except  in  emergency  calling  for  immediate    delivery  in  the  interest  of 

mother  or  child,  the  expulsion  of  the  trunk  is  left  to  nature.     It  is  not  good 

practice  to  drag  the  child  out  of  the  uterus.     The  uterus  should  be  compelled 

to  expel  it.     The  presence  of  the  trunk  and  the  extremities  stimulates  contrac- 

1 "  The  Direction  of  the  Incision  in  Episiotomy,"  Trans.  Am.  Gyn.  Soc,  1892. 


delivery,  from  nature,  R.  L.  Dickinson) :  A,  direc- 
tion of  incision  faulty,  pointing  toward  the  pos- 
terior vaginal  wall :  B,  correct  line  of  incision, 
running  parallel  with  the  axis  of  the  vulvar 
opening. 


THE    CONDUCT   OF  NORMAL    LABOR. 


425 


tions,  and   time  is  permitted  for  retraction.     When  necessary  the  expulsion 
of  the  trunk  may  be  hastened  by  the  use  of  friction  over  the  uterus. 
The  frequency  with  which  perineal  injuries  occur  during  the  delivery  of 


Fig.  206. — Episiotomy  (R.  L.  Dickinson).  Direction  of  incision :  The  black  line  shows  the  direction 
which  the  incision  should  have,  as  it  appears  after  delivery,  in  line  with  the  axis  of  the  vulvo-vaginal 
outlet;  the  dotted  line  illustrates  a  faulty  incision,  dipping  into  the  middle  section  of  the  pelvic  floor. 

the  shoulders  is  probably  exaggerated.  It  is  easy  to  attribute  to  the  shoulders 
a  rupture  which  had  occurred  undiscovered  during  the  birth  of  the  head. 

On  the  expulsion  of  the  head  the  face  should  be  bathed,  and  the  skin 
about  the  eyes  should  carefully  be  cleansed  and  thoroughly  dried  as  a  pre- 
ventive against  ophthalmia.  Mucus  in  the  pharynx  should  quickly  be 
removed  by  the  finger  covered  with  a  piece  of  soft  wet  muslin  or  by  the 
use  of  a  soft-rubber  tube  with  an  aspirating  bulb  attached. 

Ligation  of  the  Cord. — The  time  for  tying  the  cord  is  by  no  means  a  mat- 
ter of  indifference.  Systematic  observations  have  shown  that  the  child  gains 
from  1  to  3  ounces  of  blood  by  delaying  the  ligation  for  several  minutes  after 
birth ;  that  in  cases  thus  treated  the  children  are  notably  more  robust  than 
when  immediate  ligation  has  been  practised,  and  that  the  usual  loss  of  weight 
during  the  first  few  days  of  infancy  is  diminished. 

This  post-natal  transfusion  of  blood  is  a  fact  of  no  little  importance, 
especially  in  prematurely  born  and  anemic  or  puny  children.  According 
to  Budin  and  Ribemont,  it  is  mainly  the  result  of  thoracic  aspiration. 
Schiicking,  Porak,  and  Fritsch,  however,  attribute  it  chiefly  to  the  pres- 
sure exerted  upon  the  placenta  by  the  uterine  contraction  and  retraction. 
Caviglia,  who  has  recently  restudied  the  subject,1  supports  the  latter  opinion. 
He  calls  attention  to  the  fact  that  since  there  is  frequently  a  diminution 
1  Nouvelles  Arch.  d'Obstet.  et  de  Gyn.,.\il.  Annee,  Nos.  11,  12,  et  viii.  Annee,  Nos.  1,  2. 


426  AMERICAN    TEXT-BOOK   OF    OBSTETRICS. 

of  the  weight  of  the  child  in  the  first  moments  after  birth  from  relaxation 
of  the  uterus,  too  early  ligation  of  the  cord  exposes  the  new-born  infant  to 
the  loss  not  only  of  reserve  blood,  but  also  to  a  part  of  its  own.  Still  later 
observations  sustain  the  views  of  Budin  and  Eibemont. 

Since  the  child's  heart  may  be  endangered  by  forcing  too  much  blood  into 
the  circulation,  compression  of  the  uterus  should  not  be  practised  before  the 
cord  is  tied. 

Iu  certain  emergencies  immediate  ligation  may  be  necessary,  owing  to  con- 
ditions of  the  mother  requiring  the  obstetrician's  entire  attention.  In  case  of 
well-developed,  vigorous  infants  the  rule  of  late  ligation  loses  much  of  its 
importance. 

The  practice  now  usually  observed  is  to  tie  the  cord  after  notable  pulsation 
has  ceased    and  the  respiration    is  full}-  established. 

In  case  of  twins  the  cord  should  always  be  ligated  on  the  maternal  as  well 
as  on  the  fetal  side,  owing  to  the  possible  existence  of  a  vascular  connection 
between  the  two  placentas. 

A  suitable  material  for  the  ligature  is  narrow  linen  bobbin.  For  greater 
security  against  hemorrhage  a  rubber  elastic  band  may  be  used.  It  is  perhaps 
needless  to  say  that  the  material  should  be  surgically  clean.  It  may  be  left  in 
the  antiseptic  solution  until  wanted. 

The  common  practice  is  to  tie  from  one  and  a  half  to  three  inches  away 
from  the  umbilicus.  For  this  rule,  in  the  absence  of  a  navel-cord  hernia, 
there  is  apparently  no  better  reason  than  custom.  It  is  in  the  interest  of  an 
aseptic  healing  of  the  navel  wound  to  reduce  to  a  minimum  the  amount  of 
necrotic  material  in  the  stump.  The  ligature  should  therefore  generally  be 
placed  not  more  than  half  an  iuch  from  the  cutaneous  line.  It  is  to  be  tied 
as  tightly  as  it  can  be  drawn,  with  care  to  put  no  strain  on  the  umbilical 
insertion.  Before  tying,  the  cord,  except  it  be  already  thin,  should  be  pinched 
firmly  between  the  thumb  and  finger  at  the  point  to  be  ligated.  This  procedure 
is  better  than  stripping,  which  is  liable  to  do  violence  to  the  navel. 

The  cord  is  divided  within  a  quarter-inch  of  the  ligature.  It  is  cut  with 
clean  scissors  while  held  in  the  hollow  of  the  hand  to  guard  against  injuring 
the  child.  A  bit  of  cheese-cloth  pressed  a  few  times  against  the  cut  end  of 
the  stump  will  show  whether  the  vessels  are  securely  tied.  It  is  a  common 
practice  to  place  a  second  ligature  a  short  distance  from  the  first  to  control 
the  maternal  end  of  the  cord.  This  promotes  cleanliness  and,  it  is  gener- 
ally believed,  favors  the  placental  expulsion.  The  latter  claim,  however,  is 
doubtful.     The  writer  omits  the  second  ligature. 

Management  of  the  Third  Stage. 

Not  the  least  important  duties  of  the  obstetrician  in  the  conduct  of  natural 
labor  fall  in  the  third  stage.  Upon  the  skill  and  attention  given  to  this  jieriod 
the  immediate  safety  of  the  woman  and  the  rapidity  and  completeness  of  her 
recovery  will  often  in  great  measure  depend.  The  chief  dangers  of  this  stage 
are  those  which  grow  out  of  a  relaxed  condition  of  the  uterus — hemorrhage, 


THE    CONDUCT   OF  NORMAL    LABOR. 


427 


embolism,  and  the  retention  of  clots  favoring  sepsis  and  subinvolution.  The 
management  of  the  third  stage  is  therefore  mainly  addressed  to  uterine  con- 
traction and  retraction.  From  the  moment  the  head  is  born  the  uterus  should 
constantly  be  watched,  with  the  hand  held  flat  upon  the  abdomen  over  the  fun- 
dus, until  evacuation  is  complete  and  the  uterine  globe  as  hard  as  a  cricket-ball. 
After  the  expulsion  of  the  child  the  patient  is  placed  on  her  back.  The  nurse, 
if  she  is  competent,  may  be  trusted  to  hold  the  fundus,  at  least  while  the  phy- 


Fig.  207.— CrediS's  method  of  expressing  the  ] 


sions  (photographed 


sician  is  occupied  with  other  duties.  The  hand  is  to  be  held  quietly  upon  the 
abdomen  so  long  as  the  uterus  retains  its  normal  consistence.  Should  the  con- 
tractions be  feeble,  they  may  be  stimulated  by  gentle  friction.  This  stimulation 
is  best  practised  by  moving  the  lax  abdominal  walls  over  the  uterus  with  a  cir- 
cular motion  of  the  hand.  More  active  interference  is  seldom  required  in  nor- 
mal cases.  Marked  flabbiness  of  the  uterine  tumor  and  indistinctness  of  out- 
line call  for  more  energetic  measures  to  provoke  contraction. 

When  the  placenta  is  not  expelled  after  a  reasonable  time,  resort  should  be 
had  to  the  method  of  Crede,  as  follows  :  A  half  hour  after  the  termination  of 
the  second  stage  is  allowed  for  the  detachment  of  the  after-birth.  If  at  the 
expiration  of  that  time  the  placenta  is  still  undelivered,  friction  is  applied  to 
the  uterus  until  a  vigorous  contraction  is  induced.  The  hand  is  then  placed  in 
such  position  upon  the  abdomen  that  the  fundus  rests  in  the  hollow  of  the 
hand  with  the  thumb  in  front  and  the  four  fingers  behind  (Fig.  207).    At  the 


428  AMERICAN    TEXT-BOOK   OF    OBSTETRICS. 

height  of  the  contraction  the  uterus  is  compressed  and  thrust  downward  in  the 
direction  of  the  pelvic  axis.  If  not  at  once  successful,  the  process  is  repeated 
at  short  intervals  until  the  object  is  gained.  Until  recently  Crede  advocated 
much  earlier  interference.  Shortly  before  his  death  he  recommended  waiting 
thirty  minutes.  His  procedure  is  now  generally  adopted.  The  expectant  plan 
still  advocated  by  certain  authorities  is  open  to  the  objection  that  the  placenta 
may  be  retained  for  hours,  during  which  the  patient  is  exposed  to  the  danger 
of  hemorrhage  and  is  deprived  of  much-needed  repose. 

Traction  upon  the  cord  while  the  after-birth  lies  in  the  upper  uterine  seg- 
ment is  inconsistent  with  the  normal  mechanism  of  placental  expulsion.  When 
the  placenta  has  passed  into  the  lower  segment  of  the  uterus  or  the  vagina,  no 
harm  will  be  clone  by  gently  pulling  the  cord  to  assist  the  delivery. 

As  the  placenta  is  extruded  the  membranes  are  gradually  detached  from 
the  uterus,  care  being  taken  that  no  fragments  are  torn  off  and  left  behind. 
To  prevent  this  the  placenta  is  caught  in  the  hand  as  soon  as  it  passes  the 
vulva,  and  if  the  membranes  are  not  already  free  they  should  be  twisted  into 
a  rope  by  turning  the  placenta  over,  and  the  twisting  continued  until  the 
separation  is  complete.  Should  a  strip  of  membrane  accidentally  be  left  in  the 
passages,  it  may  be  removed,  if  in  the  vagina  or  hanging  from  the  cervix,  by 
grasping  it  with  the  fingers  and  gently  drawing  it  away,  or  by  seizing  it  with 
sterilized  catch-forceps  and  twisting  it  off.  Fragments  of  membranes  remain- 
ing wholly  in  the  uterine  cavity  above  the  cervix  are,  as  a  rule,  better  left  to 
be  expelled  with  the  lochial  discharge  unless  they  give  rise  to  hemorrhage. 
Placenta  and  membranes  must  be  examined  carefully  to  see  if  they  are  com- 
plete. Possible  anomalies  of  the  after-birth  or  the  cord  may  also  be  looked 
for.  To  make  sure  that  both  amnion  and  chorion  are  entire  the  membranes 
are  best  examined  by  transmitted  light. 

The  duties  of  the  obstetrician,  even  in  strictly  normal  labor,  are  by  no 
means  ended  with  the  delivery  of  the  after-birth.  The  third  stage  is  not  com- 
plete until  uterine  retraction  is  fully  established.  For  at  least  a  half-hour 
after  the  placenta  comes  away  the  uterus  is  to  be  watched  with  the  hand  upon 
the  abdomen,  using  friction  if  necessary  to  provoke  contraction.  It  is  a  useful 
precaution  to  give  a  half-drachm  of  the  fluid  extract  of  ergot  at  the  close  of 
labor  if  the  uterus  is  not  firmly  contracted.  Its  use  is  proper  only  after 
evacuation  of  placenta,  membranes,  and  clots.  Its  action  is  most  prompt 
and  certain  when  injected  subcutaneously.  One  or  two  doses  may  be  left 
with  the  patient  with  instructions  that  they  be  taken  in  the  event  of  flow- 
ing too  freely.  The  use  of  a  moderate  dose  of  ergot  at  the  close  of  labor 
is  not  only  harmless,  but  it  is  also  entirely  in  keeping  with  the  objects  of 
treatment  at  this  period.  It  limits  the  clanger  of  hemorrhage,  and  by  dimin- 
ishing the  blood-supply  it  promotes  involution.  It  tends  to  close  the  gates 
against  infection,  to  guard  against  the  retention  of  blood-clots  in  uterine 
cavity,  and  therefore  it  lessens  the  tendency  to  after-pains  and  to  putrid 
accumulations  in  the  uterus. 

Repair  of  Laceeatioxs. —  Cervical  laeerations  should  be  sutured  at  the 


THE    CONDUCT    OF  NORMAL    LABOR. 


429 


close  of  labor  in  case  they  give  rise  to  much  hemorrhage.     In  the  absence  of 
troublesome  bleeding  the  advantage  of  the  primary  suture  is  doubtful. 

The  method  of  operating  is  as  follows.  No  anesthetic  is  required.  The 
cervix  is  most  readily  brought  down  within  easy  reach  when  the  patient  is  on 
the  back.  She  may  lie  across  the  bed  with  the  hips  close  to  its  edge,  or  still 
better  on  a  firm  table.  If  necessary,  the  perineum  may  be  retracted  with  a 
large  Sims  speculum.  The  anterior  vaginal  wall  may  be  held  up  out  of  the 
way  with  a  retractor,  if  required.  The  cervix  is  drawn  well  down  with  a 
volsella.  The  lips  of  the  wound  are  most  conveniently  held  in  contact  with  a 
single  volsella,  one  hook  being  caught  in  each  lip  near  the  lower  end  of  the 
tear.  The  first  suture  should  be  passed  just  above  the  upper  angle  of  the 
laceration  and  tied.  This  suture,  if  properly  placed,  controls  the  bleeding. 
The  other  sutures  are  then  applied  as  in  the  secondary  operation.  The  mate- 
rial may  be  waxed  silk  or  silver  wire.  The  former  is  recommended  as  being 
more  manageable,  and  it  has,  in  the  writer's  experience,  proved  entirely  satis- 
factory when  well  saturated  with  paraffin  wax. 

Lacerations  of  the  pelvic  floor  in  general  practice  probably  occur  in  not  less 
than  35  per  cent,  of  first  and  in  about  10  per  cent,  of  subsequent  labors. 
This  percentage  of  injuries,  however, 
is  capable  of  considerable  reduction 
under  proper  management  of  the  per- 
ineal stage  of  the  birth.  In  skilfully 
conducted  labors  the  proportion  of  lac- 
erations should  scarcely  exceed  15  per 
cent.  In  case  of  relatively  small  vulvo- 
vaginal orifice,  narrow  pubic  arch,  un- 
usual rigidity  of  the  pelvic  floor, 
breech  extraction,  and  other  rapid 
deliveries,  notable  injuries  are  inevi- 
table in  a  large  proportion  of  cases. 

The  type  of  laceration  most  fre- 
quently encountered  is  one  that  runs 
nearly  in  the  median  line  of  the  super- 
ficial structures  and  to  one  side  of  it  in 
the  vagina  (Fig.  208).  Sometimes 
the  wound  presents  the  shape  of  a  Y 
with  one  arm  to  either  side  of  the 
median  line. 

Time  for  Repair. — Unless  the  con- 
dition of  the  patient  at  the  close  of 
labor  is  such  as  to  forbid — and  this  is  very  rarely  the  case — lacerations  of  the 
pelvic  floor  should  immediately  be  sutured.  Yet  perfect  union  may  be  obtained 
by  operating  at  any  time  within  twenty-four  hours.  The  suturing  may 
generally  be  done  with  complete  success  even  after  so  long  a  period  as  a 
week  if  for  any  reason  it  has  previously  been  neglected.     When  performed 


Fig.  208— Laceration  of  the  pelvic  floor,  extending 
halfway  to  the  rectum  and  running  toward  the  right 
vaginal  sulcus  (from  a  sketch  at  the  close  of  labor  by 
Robert  L.  Dickinson,  M.  D.). 


430  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

thus  late  the  wound-surfaces  may  first  be  vivified  by  rubbing  them  with  a 
fold  of  cheese-cloth,  aud  then  made  smooth  by  trimming  with  scissors. 

The  writer  has  frequently  repaired  lacerations  while  waiting  for  the 
delivery  of  the  placenta.  This  practice  saves  time,  and  generally,  too,  the 
renewal  of  the  anesthesia.  It  is  not  to  be  advised  in  extensive  and  compli- 
cated injuries. 

Suture  Material. — For  most  uses  silkworm-gut  is  recommended.  Catgut 
is  theoretically  objectionable  for  surface  work,  owing  to  its  tendency  when 
partially  exposed  to  decompose  and  to  lead  septic  material  into  the  needle- 
track  ;  yet  in  practice  chromated  catgut  answers  well,  especially  within  the 
vagina. 

Needles. — For  use  in  the  external  and  more  accessible  portion  of  the  wound 
the  needle  should  be  straight  or  be  slightly  curved  and  about  2  inches  in 
length.  For  suturing  tears  high  up  in  the  vagina  a  needle  as  much  shorter  as 
the  depth  of  the  wound  will  permit,  and  having  a  more  pronounced  curve,  may 
more  conveniently  be  used.  Needles  of  the  Hagedorn  pattern  will  be  found 
satisfactory. 

Method. — An  anesthetic  is  usually  necessary.  Ether  is  to  be  preferred 
here,  as  usual  for  surgical  anesthesia.  Small  tears  may  be  repaired  under 
cocain  anesthesia  if  for  any  reason  it  is  desirable  to  avoid  the  use  of  the 
general  anesthetic.  Cocain  is  most  effective  when  injected  at  several  points  in 
the  lips  of  the  wound.  Not  more  than  a  grain  at  most  can  safely  be  used  in 
this  manner,  and  the  solution  should  be  rendered  sterile  by  boiling.  Many 
women,  however,  suffer  very  little  pain  from  the  introduction  of  sutures,  since 
the  tissues  have  largely  lost  their  sensitiveness  by  the  pressure  and  contusion 
received  during  labor.  If  care  is  taken  to  plunge  the  needle  quickly  through 
the  skin-margin  at  the  moment  the  greatest  amount  of  pain  is  produced, 
lacerations  not  very  extensive  may  be  sutured  without  anesthesia.  The 
patient  lies  in  the  lithotomy  position,  crosswise  of  the  bed,  with  the  hips  close 
to  the  edge  of  the  latter,  or  upon  a  table.  The  knees  are  held  by  assistants  or 
by  some  of  the  numerous  appliances  commonly  employed  for  the  purpose  in 
gynecological  practice.  The  sheet  sling  of  Dr.  Dickinson  has  the  advantage 
of  being  always  available. 

One  of  the  chief  difficulties  in  determining  the  extent  and  character  of  the 
laceration  arises  from  the  continuous  flow  of  blood  over  the  parts,  obscuring 
the  view.  It  is  generally  advisable,  therefore,  to  pack  the  vagina  above  the 
wound  with  sterile  gauze,  care  being  taken  to  remove  it  after  the  operation. 
Loose  tags  of  tissue  which  might  become  necrotic  should  be  trimmed  off  with 
scissors. 

The  type  of  laceration  most  frequently  met  with,  as  previously  stated, 
runs  up  one  or  both  sides  of  the  vaginal  orifice.  The  aim  must  be  to  re- 
establish completely  the  normal  relations  of  the  injured  structures.  The 
sutures  may  be  applied  from  the  skin-surface  when  the  depth  of  the  wound 
thus  included  in  each  suture  would  not  exceed  an  inch.  The  sutures  are 
placed  at  intervals  of  half  an  inch,  beginning  at  the  posterior  angle  of  the 


THE    CONDUCT   OF  NORMAL    LABOR.  431 

wound,  nearest  the  anus.  Enter  the  needle  ivpon  the  skin  close  to  the  edge 
of  the  wound.  Give  it  a  large  circular  sweep,  and  let  it  emerge  in  the 
wound  well  down  at  the  bottom  of  the  tear;  then  pass  it  symmetrically 
through  the  opposite  lip  in  reversed  direction,  entering  at  the  bottom  of  the 
laceration  and  emerging  on  the  skin  surface  at  the  edge  of  the  wound.  Care 
must  be  taken  to  avoid  entering  the  rectum.  The  course  of  the  suture  should 
be  such  that  when  tied  the  loop  shall  be  nearly  circular.  Each  stitch  after 
insertion  is  temporarily  tightened  as  if  for  tying,  to  see  that  it  has  sweep  enough 
to  hold  the  wound-surfaces  in  contact  throughout  the  entire  depth  of  the 
laceration.  As  the  threads  are  placed,  one  by  one,  the  ends  are  loosely 
knotted  together  or  are  held  with  catch-forceps  until  all  are  ready  to  be  tied 
permanently.  The  gauze  packing  is  then  removed,  and  the  wound  is  cleared 
of  clots.  The  sutures  are  tied  in  the  order  of  insertion.  They  must  be 
drawn  tight  enough  barely  to  coapt,  but  not  to  constrict,  the  parts.  If  the 
sutures  are  of  non-absorbable  material,  the  ends  may  be  left  about  an  inch 
in  length  to  facilitate  removal. 

If  the  sphincter  ani  is  torn,  the  ends  are  to  be  brought  together  by  two 
or  three  buried  sutures  of  catgut.  In  complete  laceration  of  the  sphincter 
the  muscle-ends  tend  to  retract  deeply  in  the  tissues.  In  these  cases  by  close 
inspection  a  pocket  or  depression  may  be  detected  in  the  wound-surface  on 
either  side  of  the  median  line.  This  depression  marks  the  location  of  the 
retracted  end  of  the  torn  sphincter.  The  end  of  the  muscle  is  to  be  caught 
up  with  a  tenaculum  and  drawn  well  out  as  the  suture  is  passed  on  either 
side.  One  or  two  tension  sutures  of  silkworm-gut  are  introduced  through 
the  skin  and  passed  directly  through  the  sphincter  on  each  side  of  the  tear 
just  without  the  buried  coaptation  sutures  of  catgut.  Care  must  be  taken 
to  have  no  dead  space  above  the  sphincter. 

Tears  involving  the  vagina  are  best  sutured  on  the  vaginal  surface  nearly 
or  quite  down  to  the  region  of  the  hymen.  These  stitches  are  passed  at  a 
right  angle  to  the  vaginal  axis.  The  rest  of  the  wound  is  then  sutured  from 
the  skin-surface  as  already  described,  the  plane  of  each  of  the  latter  sutures 
being  nearly  at  a  right  angle  to  that  of  the  skin. 

Complete  teal's,  extending  into  the  rectum,  may  be  stitched  on  the  vaginal, 
the  perineal,  and  the  rectal  surfaces.  Owing  to  the  difficulty  of  removing 
silk  from  the  rectum,  rectal  sutures  should  be  of  catgut.  They  should  include 
little  more  than  the  mucous  membrane  of  the  bowel.  The  rectal  side  of  the 
laceration  is  closed  first,  the  knots  being  tied  in  the  rectum,  resting  upon  its 
mucous  membrane,  and  the  remaining  wound  is  sutured  on  either  the  perineal, 
the  vaginal,  or  both  surfaces  as  may  be  found  most  expedient.  When  the  rent 
does  not  extend  up  the  rectum  too  far,  in  addition  to  the  last  interrupted  sutures 
tied  in  the  rectum,  which  coapt  the  torn  ends  of  the  sphincter,  a  reinforcing 
stitch  will  be  useful  passed  in  the  following  manner :  While  a  tenaculum  is 
used  to  draw  out  one  retracted  end  of  the  muscle,  the  suture  is  passed  through 
this  end  of  the  muscle,  and  continues  its  course  upward,  buried  along  the  edge 
of  the  rectal  rent,  to  the  apex  of  the  rent ;  the  needle  now  emerges,  and  is  again 


432 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


buried  along  the  other  margin  of  the  rectal  rent,  and  is  carefully  passed 
through  the  other  end  of  the  torn  sphincter,  while  a  tenaculum  draws  out  this 
retracted  end  of  the  muscle. 

In  deep  tears  of  any  kind  the  tiered  suture  is  a  good  one.  Beginning  at 
one  end  of  the  wound,  a  layer  of  the  torn  structures  at  the  bottom  of  the 
laceration  is  closed  with  a  running  catgut  suture ;  this  is  repeated  in  a  plane 
next  above  the  first,  and  so  on  until  the  wound  is  entirely  closed.  The  right 
and  the  wrong  methods  of  suturing  are  shown  in  Figures  209  to  211. 

After-care. — There  is  no  necessity,  as  a  rule,  for 
tying  the  patient's  knees  together.  The  sensitive- 
ness of  the  parts  will  be  a  sufficient  safeguard 
against  injurious  strain  upon  the  sutures  by  sepa- 
rating the  limbs,  and  the  patient  will  be  much  more 
comfortable  without  the  leg-binder. 

Retention  of  urine  frequently  results,  owing  to 
the  reflex  disturbance  caused  by  the  perineal  suture, 
especially  when  the  latter  comes  close  to  the  rectum. 
While  injurious  distention  of  the  bladder  must  not 
be  permitted,  the  catheter  should  be  withheld  if 
possible.  Whether  the  bladder  is  emptied  volun- 
tarily or  otherwise,  urine  must  not  be  permitted  to 
trickle  into  the  vagina  or  over  the  suture-line.  The 
bowels  are  to  be  kept  open,  as  in  other  cases,  after 
the  second  day.  Non-absorbable  sutures  are  re- 
moved on  the  eighth  or  the  ninth  day. 

Toilet  of  the  Patient. — The  child  is  received  in 
two  or  three  thicknesses  of  flannel,  is  well  wrapped, 
and  is  laid  in  a  warm  place.  The  nurse  then  turns 
her  attention  to  the  mother  :  soiled  portions  of  her 
body  are  to  be  cleansed,  best  with  an  antiseptic 
solution  ;  her  linen,  if  necessary,  is  changed  ;  and  all  blood-stained  articles 
are" removed  from  the  bed.  For  bathing  the  genitals  a  piece  of  fresh-boiled 
cheese-cloth  or  towelling  is  to  be  used  instead  of  a  sponge.  Sea-sponges 
should  be  banished  from  the  lying-in  room.  New  sponges  are  difficult  to 
clean,  and  the  ordinary  household  article  is  dangerously  filthy. 

Vulvar  Dressing. — After  cleansing,  the  vulva  is  covered  with  an  aseptic 
dressing.  A  fresh-laundered  napkin  is  suitable,  or  a  lochial  guard  specially 
made  for  the  purpose  may  be  employed.  These  guards  are  made  of  absorbent 
cotton,  of  cotton  waste,  or  of  prepared  jute  enveloped  in  cheese-cloth.  Suit- 
able dimensions  are  about  10  inches  long,  4  inches  wide,  and  2  inches  thick. 
Tail-pieces  are  attached  to  the  guards  for  fastening  to  the  binder.  The  guards 
are  burned  after  using.  These  dressings  are  best  sterilized  by  steaming  imme- 
diately before  use.  Flowing  steam  is  most  effective.  They  are  not  employed 
as  occlusion  dressings.  Their  object  is  rather  to  promote  the  cleanliness  of  the 
external  parts,  thus  limiting  the  danger  of  infecting  the  passages  from  the  prox- 


FiG.  209.— Laceration  like  that 
shown  in  Figure  208,  with  sutures 
properly  placed  ready  for  tying. 


CONDUCT  OF  NORMAL   LABOR. 


1.  Abdominal  binder  and  breast-binder  in  place  (from  a  photograpb).     2.  Breast-binder  in  place 
(from  a  photograph). 


THE    CONDUCT    OF  NORMAL    LABOR. 


433 


imity  of  decomposing  discharges.    The  use  of  some  non-irritant  antiseptic  like 

boric  acid,  bismuth  powder,  or  iodoform  helps  to  retard  putrefactive  changes. 

One  rubber  sheet  should  be  left  in  place  under  the  linen  for  four  or  five  days. 


■_-  6 


Fig.  210.— A,  faulty  method  of  suture,  falling  short  of  the  bottom  of  wound  and  not  catching  all  the 
musele-ends  :  a,  before  tying ;  b,  after  tying.  The  latter  figure  shows  dead  space  at  the  bottom  of  wound 
after  tying;  perineal  body  only  partially  restored.  B,  suture  improperly  placed:  a,  before  tying;  b,  after 
tying.  The  suture  (a)  has  too  little  lateral  sweep,  and  it  does  not  include  the  ends  of  all  the  retracted 
muscle-fibres  at  the  sides  of  the  wound ;  b  shows  the  result,  the  pelvic  floor  being  imperfectly  restored. 

A  draw-sheet  placed  under  the  patient's  hips  is  a  convenient  dressing  for  pro- 
tecting the  bed.  The  draw-sheet  consists  of  a  common  muslin  sheet  folded 
to  four  thicknesses.  It  is  replaced  by  a  fresh  one  as  often  as  soiled.  Instead 
of  the  draw-sheet  an  aseptic  pad  similar  to  the  labor-pad,  but  thinner  and 
smaller,  may  be  preferred. 

Abdominal  Binder. — The  abdominal  binder  is  useful  to  steady  the  uterus, 
and  it  promotes  the  comfort  of  the  patient,  especially  when  the  abdominal  walls 


Fig.  211.— Shows  full  sweep  of  a  properly  placed  suture  :  a,  before  tying;  6,  after  tying.  Even  though 
the  tear  runs  in  different  planes  at  different  depths,  the  muscle-ends  are  held  in  apposition  throughout 
the  entire  depth  of  the  wound. 

are  very  lax.  The  usual  material  is  a  piece  of  unbleached  muslin  1  \  yards 
in  length  and  about  18  inches  in  width.  This  gives  width  enough  to  reach  from 
the  ensiform  to  a  point  below  the  trochanters  (PI.  27,  Fig.  1).  Unless  the 
binder  overreaches  these  bony  prominences  it  is  liable  to  slip  up,  and  in  a  few 
hours  is  reduced  to  a  mere  rope  around  the  body.  Binders  ready  made  with 
gores  to  fit  the  body  offer  no  advantage.     The  pinning  of  the  binder  should 


434  AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 

begin  at  the  lower  border,  and  at  the  first  application  should  be  fairly  tight. 
If  the  uterus  shows  aDy  tendency  to  relaxation,  three  folded  towels,  used  as 
compresses,  may  be  placed  on  the  abdomen  under  the  bandage,  one  on  either 
side  of  the  uterus  and  one  immediately  above  it.  The  binder  may  be  dis- 
pensed with  after  one  or  two  weeks. 

Before  leaving,  the  physician  takes  final  note  of  the  pulse  and  the  general 
condition  of  the  mother,  and  gives  full  instructions  to  the  nurse  for  the  gen- 
eral care  of  both  patients. 


III.  THE  MECHANISM  OF   LABOR. 

Labor  is  a  natural  process,  and  it  is  the  province  of  the  accoucheur  to 
restrict  himself  to  watching  the  processes  of  nature  so  long  as  they  are  normal 
and  efficient,  and  to  interfere  with  them  only  when  they  become  disturbed  or 
inefficient.  He  is  at  his  best  when  he  is  able  to  compel  the  faulty  efforts  of 
natural  labor  into  a  normal  course,  and  he  makes  a  comparative  failure  when- 
ever he  is  obliged  to  substitute  for  the  acts  of  nature  the  relatively  crude 
process  of  an  artificial  delivery.  An  ability  to  restore  the  normal  by  making 
trifling  alterations  in  the  mechanical  conditions  presupposes,  however,  a  most 
accurate  knowledge  of  the  details  of  the  mechanism  which  governs  the  usual 
course  of  labor,  and  of  the  alterations  in  them  which  determine  the  advent 
of  any  deviation  from  the  normal.  When,  moreover,  it  is  remembered  that 
obstetric  operations  are  but  efforts  to  direct  an  extraneous  force  into  an  accu- 
rate imitation  of  the  processes  of  nature,  it  becomes  evident  that  the  first 
essential  to  success  in  obstetrics  is  the  possession  of  a  far-reaching  knowledge 
of  the  mechanism  of  labor  in  its  several  varieties. 

Any  intelligent  study  of  obstetrical  mechanism  must,  however,  be  preceded 
by  a  comprehension  of  the  technical  terms  used  in  describing  it,  and  of  the 
several  classifications  by  which  labor  is  commonly  subdivided  into  varieties. 
It  is  further  necessary  that  the  student  should  possess  an  accurate  knowledge 
of  the  shape  and  dimensions  of  the  obstetric  canal,  and  of  the  fetus  which  is 
to  pass  through  it.  He  is  then  in  a  position  to  acquire  an  intelligent  under- 
standing of  the  principles  which  underlie  the  mechanism  of  all  the  forms  of 
labor,  under  the  head  of  a  description  of  its  commonest  variety,  and  so  easily 
goes  on  to  understand  the  modifications  in  the  mechanism  that  follow  upon 
the  alterations  in  the  conditions  in  the  other  varieties. 

Attitude  of  the  Fetus. — By  the  attitude  of  the  fetus  is  meant  the  posi- 
tion its  parts  assume  in  ulero  in  relation  to  one  another,  in  contradistinction 
to  any  relation  they  may  bear  to  the  maternal  parts. 

During  the  earlier  months  of  pregnancy  the  uterine  cavity  is  nearly 
spherical  in  shape,  and  it  is  then  so  large  in  proportion  to  the  fetus  that  its 
walls  are  rarely  in  contact  with  the  embryo.  The  fetus  hangs  freely  in  the 
uterine  cavity,  being  suspended  by  the  umbilical  cord,  with  its  head  usually 
somewhat  lower  than  its  pelvis  and  its  limbs  in  a  somewhat  extended  posi- 


THE   MECHANISM   OF  LABOR.  435 

tion  (Fig.  212).    As  pregnancy  progresses  the  size  of  the  fetus  increases  more 
rapidly  than  that  of  the  uterus,  until  in  normal  cases  at  term  the  adaptation 


Fig.  212.— Relation  between  the  size  of  the  uterus  and  the  fetus  at  fifth  month  (fetus  one-sixth  natural 

size). 

between  the  two  is  sufficiently  close  to  make  any  extended  movements  of  the 
fetal  limbs  difficult  or  impossible.    The  attitude  which  the  child  then  assumes 


Fig.  213.— Adaptation  between  the  uterus  and  the  fetus  at  term,  in  vertex  presentations  (one-sixth  nat- 
ural size). 

is  that  represented  in  Figure  213,  which  is  readily  seen  to  be  the  most  com- 
pact attitude  in  which  the  child  can  be  arranged. 

Presentation. — The  word  j))'esentation  is  used  to  define  the  relation  which 
the  long  axis  of  the  child  bears  to  the  long  axis  of  the  uterus,  aud  the  dif- 
ferent presentations  are  distinguished  from  one  another  by  the  use  of  adjec- 
tives which  refer  to  the  part  of  the  child  that  is  to  enter  the  pelvis  first  in  a 
given  case.  The  several  presentations  which  may  occur  are  cephalic  presen- 
tations— that  is,  presentations  of  the  vertex,  of  the  brow,  and  of  the  face;  pres- 
entations of  the  pelvic  extremity,  which  are  subdivided  into  breech  and  foot- 
ling presentations ;  aud  transverse  presentations,  under  which  are  included 
presentations  of  the  hip,  of  the  trunk,  and  of  the  shoulder. 


436  AMERICAN   TEXT-BOOK    OF   OBSTETRICS. 

Position. — In  obstetric  use  the  word  position  is  restricted  to  a  meaning  in 
which  it  is  used  to  define  the  relation  that  the  dorsum  of  the  child  bears  to 
the  dorsum  of  the  mother  during  its  passage  through  the  pelvic  canal.  Each 
presentation  is  subdivided  into  positions  according  as  the  dorsum  of  the  child 
is  directed  anteriorly  or  posteriorly  and  toward  the  right  or  the  left  side  of  the 
mother.  Thus  we  recognize  under  each  presentation  four  positions,  according 
to  whether  the  part  which  gives  the  name  to  the  position  is  directed  left- 
anteriorly,  right-anteriorly,  right-posteriorly,  or  left-posteriorly ;  for  example, 
vertex  presentation,  occipito-left-anterior,  breech  presentation,  sacro-right- 
posterior. 

Classification  of  Labor. 

Presentations. — The  presentations  are  first  of  all  roughly  divided  into 
longitudinal  and  oblique  presentations.  The  longitudinal  presentations  are 
those  in  which  the  long  axis  of  the  fetus  is  in  correspondence  with  the  long 
axis  of  the  uterus ;  the  oblique  presentations  are  those  in  which  there  is  a 
considerable  angle  between  the  two  axes. 

The  longitudinal  jwesentations  are,  then,  those  in  which  either  the  cephalic 
or  the  pelvic  end  of  the  fetus  is  found  at  the  inlet  of  the  pelvis  at  the  begin- 
ning of  labor — that  is,  all  the  variations  of  cephalic  and  pelvic  presentations. 

The  oblique  or  transverse  presentations  include  all  those  in  which  any  por- 
tion of  the  fetus  other  than  the  head  or  the  breech  is  found  at  the  pelvic 
brim. 

Head  presentations  are  divided  into  those  of  the  vertex,  of  the  brow,  and 
of  the  face.  Pelvic  presentations  are  divided  into  breech  presentations,  in 
which  both  thighs  are  flexed  upon  the  abdomen  when  the  nates  of  the  fetus 
enter  the  mother's  pelvis,  and  footling  presentations,  in  which  one  or  both 
legs  are  extended  and  enter  in  advance  of  the  infant's  pelvis.  Transverse 
presentations  include  presentations  of  the  hip,  of  the  trunk,  and  of  the 
shoulder;  among  these  presentations  those  of  the  shoulder  are  by  far  the 
commonest  and  most  important. 

It  is  also  convenient  to  classify  the  presentations  of  the  fetus  in  two  other 
ways,  in  accordance  with  the  results  which  may  be  expected  to  accrue  from 
their  occurrence — namely,  into  normal  and  abnormal,  natural  and  unnatural, 
presentations. 

Normal  and  Abnormal  Presentations. — A  presentation  of  the  vertex 
occurs  in  about  97  per  cent,  of  all  labors,  and,  both  from  its  frequency  and 
from  the  favorable  character  of  its  results,  is  considered  to  be  the  only  normal 
presentation,  all  others  being  classified  as  abnormal. 

Natural  and  Unnatural  Presentations. — Natural  presentations  are  those 
in  which  the  conditions  are  such  that  they  may  be  expected  to  terminate,  in  a 
large  proportion  of  cases,  in  delivery  by  natural  or  unaided  labor.  Unnatural 
presentations  are  those  in  which  the  shape  of  the  presenting  part  of  the  fetus 
is  so  ill-adapted  to  the  pelvic  canal  that  the  labor  can  ordinarily  be  terminated 
onlv  bv  the  intervention  of  the  obstetric  art,  natural  delivery  being  possible 
onlv  when  the  pelvis  is  exceptionally  large  and  when  the  fetus  is  at  the  same 


THE  MECHANISM   OF  LABOR.  437 

time  immature  or  exceptionally  small.  Vertex,  face,  and  breech  presentations 
are  classified  as  natural ;  brow  and  transverse  presentations  are  classified  as 
unnatural. 

Position. — A  division  of  the  presentations  into  varieties  in  accordance  with 
the  obstetrical  positions  is  a  matter  of  the  utmost  practical  importance,  as  the 
mechanism  and  treatment  of  labor,  and,  indeed  the  prognosis,  are  often  radi- 
cally different  in  the  several  positions  of  a  given  presentation.  For  conven- 
ience the  most  prominent  point  on  the  dorsal  side  of  the  presenting  part  is 
selected  for  the  denomination  of  the  position  in  eacli  presentation,*  in  accord- 
ance with  the  relation  it  bears  to  a  cross-section  of  the  inlet  at  the  beginning 
of  labor. 

Vertex. — Vertex  presentations  are  thus  divided  into  positions  in  accordance 
with  the  quarter  of  the  pelvis  in  which  the  occiput  is  found  at  the  beginning 
of  labor.  We  recognize  in  vertex  presentations  four  positions :  Occipito-left- 
anterior ;  occipito-right-anterior ;  occipito-right-posterior ;  and  occipito-left- 
posterior.f 

Face. — In  face  presentations  the  position  is  named  from  the  position  of  the 
chin.  The  positions  are  inento-left-anterior,  mento-right-anterior,  mento-right- 
posterior,  and  mento-left-posterior. 

Broiv. — In  brow  presentations  the  positions  are  somewhat  unsatisfactorilv 
classified  from  the  position  of  the  occipital  end  of  the  head,  as — brow,  occipito- 
left-anterior  ;  brow,  occipito-right-anterior  ;  brow,  occipito-right-posterior  ;  and 
brow,  occipito-left-posterior. 

Breech. — In  breech  presentations  the  names  of  the  positions  are  determined 
by  the  situation  of  the  sacrum,  as — sacro-left-anterior,  sacro-right-anterior, 
sacro-right-posterior,  and  sacro-left-posterior. 

Transverse. — In  shoulder  presentations  the  positions  are  named  from  the 
situation  of  the  presenting  scapula,  as — scapular-left-anterior,  scapular-right- 
anterior,  scapular-right-posterior,  and  scapular-left-posterior. 

For  convenience  the  names  of  the  various  positions  have  long  been  desig- 
nated by  a  conventional  set  of  abbreviations,  which  are  commonly  used  with- 
out the  name  of  the  presentation,  that  being  included  by  implication.  The 
abbreviations  now  in  general  use  are  those  which  were  determined  upon  by  the 
last  International  Medical  Congress  in  its  session  at  Washington,  D.  C.  Thev 
are  as  follows :  Occipito-left-anterior,  O.  L.  A. ;  occipito-right-anterior,  O.  D.JA. ; 
occipito-right-posterior,  O.  D.  P. ;  occipito-left-posterior,  O.  L.  P. ;  Mento-left- 
anterior,  etc.,  M.  L.  A.,  etc. ;  sacro-left-anterior,  etc.,  S.L.  A.,  etc. ;  scapular-left- 
anterior,  etc.,  So.  L.  A.,  etc. 

*  Except  in  face  presentations,  in  which  case  the  chin  is  chosen  on  account  of  its  promi- 
nence in  the  mechanism  of  this  variety  of  labor. 

t  The  older  obstetricians  were  accustomed  to  recognize  four  other  varieties,  in  which  the 
occiput  was  respectively  directly  posterior,  directly  anterior,  left  transverse,  and  right  trans- 
verse. It  is  now  held,  however,  that  these  positions  do  not  occur,  under  normal  conditions,  in 
normal  pelves.  Since  they  are  only  found  in  some  varieties  of  deformed  pelves  and  in  some 
other  pathological  conditions,  their  consideration  is  now  commonly  relegated  to  the  domain  of 
pathology.  +  Dextro. 


438 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


Anatomy  of  the  Pelvis. 

The  anatomy  of  the  bones  and  the  soft  parts  which  together  make  up  the 
pelvis  is  described  in  detail  in  another  portion  of  this  work,  but  for  the  com- 
prehension of  the  mechanism  of  labor  it  is  necessary  to  add  to  the  anatomical 
description  a  discussion  of  the  shape  and  dimensions  of  the  parturient  canal 
as  a  whole,  before  its  mechanical  relation  to  the  fetus  which  is  to  pass  through 
it  can  intelligently  be  discussed. 

The  parturient  canal  (Fig.  214)  may  be  divided,  for  purposes  of  descrip- 
tion, into  three  parts — the  suprapelvic,  the  pelvic,  and  the  infrapelvic  portions. 


Fig.  1U—  The  parturient  canal :  av,  axis  ofuterus ;  at,  plane  of  inlet ;  rf,  retraction-ring  ;  10,  internal  os ; 
eo,  external  os  (one-third  natural  size). 

The  suprapelvic  or  abdominal  portion  of  the  parturient  canal  is  made  up  of 
the  uterine  cavity  and  the  large  or  false  pelvis.  This  portion  of  the  pelvis 
is  classified  with  the  uterine  cavity  on  account  of  the  similarity  of  their 
functions  ;  that  is,  the  obstetric  function  of  the  large  pelvis  is  simply  that  of 
affording  a  resting-place  to  the  lower  portion  of  the  child  during  the  whole  or 


THE  MECHANISM   OF  LABOR.  439 

the  greater  portion  of  pregnancy,  and  of  guiding  the  presenting  part  to  the 
inlet  at  the  beginning  of  labor.  The  •pelvic  portion  of  the  parturient  canal 
consists  of  the  small  or  true  pelvis.  The  infrapelvic  portion  is  made  up  of 
the  soft  parts  lying  below  the  pelvic  bones,  which  parts,  though  small  and 
inconspicuous  in  the  non-parturient  state,  are  stretched  out  during  labor  into  a 
tubular  canal  which  considerably  prolongs  the  parturient  canal,  and  completes 
the  curve  of  its  lower  portion,  known  as  the  curve  of  Carus. 

An  adequate  comprehension  of  the  shape  and  the  mechanical  functions  of 
the  parturient  canal  in  its  entirety  will  best  be  attained  by  postponing  the 
description  of  the  canal  as  a  whole  until  its  subdivisions  and  component  parts 
have  been  described  in  detail. 

Suprapelvic  Portions. —  Uterine  Cavity. — The  uterus  at  term  is  a  hollow, 
ovate-shaped  viscus,  whose  cavity,  although  anatomically  a  part  of  the  par- 
turient canal,  is,  from  a  mechanical  standpoint,  less  a  part  of  the  passage 
than  the  engine  by  which  the  passenger  is  to  be  propelled.  The  function  of 
the  uterus  as  the  source  of  the  propulsive  power  by  which  labor  is  accom- 
plished will  be  discussed  later.  Its  function  as  a  portion  of  the  canal 
requires  no  special   description. 

Fake  Pelvis. — The  false  or  large  pelvis  is  that  portion  of  the  pelvis  lying 
above  the  linea  terminal  is.  It  is  composed  of  the  lumbar  vertebrae,  the 
upper  surfaces  of  the  lateral  processes  of  the  first  sacral  vertebra,  and  the 
squamous  portions  of  the  iliac  bones,  and  functionally  it  is  completed  by  the 
lower  portions  of  the  anterior  abdominal  muscles  and  their  attachments  to  the 
horizontal  rami  of  the  pubic  bones.  The  whole  thus  forms  a  funnel  whose 
sloping  walls  terminate  in  the  inlet  of  the  true  pelvis,  and  are  admirably  suited 
to  their  office  of  directing  the  presenting  part  into  the  pelvis  in  the  initial 
stage  of  labor.  Apart  from  this  point,  the  chief  practical  value  of  the  false 
pelvis  is  in  the  light  which  alterations  of  its  shape  or  of  its  dimensions  throw 
upon  the  diagnosis  of  pelvic  deformities.  To  be  in  a  position  to  detect  any 
departure  from  the  normal  shape  of  the  pelvis,  it  is  especially  important  to  be 
familiar  with  the  normal  shape  of  the  iliac  crests  and  with  the  normal  curve 
of  the  linea  terminalis. 

Although  the  crests  of  the  ilia  are  classically  described  as  presenting  an  S- 
curve,  it  must  be  remembered  that  only  one  portion  of  this  curve — namely, 
that  which  possesses  an  anterior  concavity — enters  into  the  formation  of  the 
basin  of  the  false  pelvis ;  the  other  portion  of  the  curve  is  entirely  without 
the  pelvis,  and  is  utilized  solely  for  the  attachment  of  the  sacro-iliac  ligaments 
and  the  erector  spina?  muscles.  The  shape  of  the  anterior  portion  of  this 
curve  is  such  that  the  greatest  distance  between  the  crests  is  normally  2.5  centi- 
meters (about  an  inch)  more  than  the  distance  between  the  anterior  superior  spi- 
nous processes,  the  distance  between  the  crests  being  normallv  25  centimeters 
(about  10  inches),  and  that  between  the  spines  22.5  centimeters  (about  9  inches).* 

Under  normal  circumstances  the  anterior  portion  of  the  linea  terminalis 

*  These  dimensions  are  found  to  be  somewhat  variable  among  different  races.  The  figures 
given  are  believed  to  be  approximately  correct  for  American  women. 


440 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


presents  a  uniform  curve  with  an  internal  concavity,  and  there  is  but  little,  if 
any,  projection  of  the  crest  of  the  pubes  in  or  about  the  median  line. 

Pelvic  Portion. — The  true  or  small  pelvis  comprises  all  that  portion  of 
the  pelvis  lying  below  the  linea  terminalis,  and  it  is  divided  into  three  portions 
— the  superior  strait  or  inlet,  the  inferior  strait  or  outlet,  and  the  excavation. 
It  is  formed  by  the  sacrum,  the  coccyx,  the  lower  portion  of  the  ilia,  the 
ischia,  and  the  pubes.  These  boues  taken  together  form  a  deep  basin-shaped 
cavity,  whose  posterior  wall   is   formed  by  the  sacrum   and   coccyx   and  is 


Fig.  215.— Pelvis  seen  from  above,  showing  the  decrease  in  the  transverse  diameter  from  above  downward 
(one-third  natural  size). 

sharply  curved  with  an  anterior  concavity.  The  anterior  wall  is  formed  by 
the  svmphysis,  and  is  short  and  nearly  straight.  The  lateral  walls,  which  are 
formed  by  the  lower  portions  of  the  ilia,  the  ischia,  and  parts  of  the  descend- 
ing rami  of  the  pubes,  are  irregular  in  outline  and  slope  gently  inward,  so  that 
the  transverse  diameter  of  the  pelvis  is  markedly  less  at  their  lower  than  at 
their  upper  extremities  (Fig.  215). 

At  its  upper  and  lower  limits,  which  are  known  as  the  superior  and  inferior 
straits  (Fig.  216),  the  dimensions  of  the  pelvis  are  much  less  than  in  the  inter- 
vening space,  called  the  "  excavation."  An  accurate  knowledge  of  this  por- 
tion of  the  parturient  canal  is  of  the  greatest  importance,  and  on  account  of 
its  complexity  is  most  easily  given  by  separate  descriptions  of  the  excavation 
and  of  each  of  the  straits,  after  which  description  it  will  be  easy  to  include 
that  of  the  pelvis  as  a  whole  in  the  general  description  of  the  parturient  canal 
that  follows  at  the  end  of  this  section. 

The  superior  strait  is  bounded  by  the  promontory  and  the  anterior  surface 
of  the  first  sacral  vertebra,  the  linea  terminalis,  and  the  pubic  crests.  The 
shape  of  the  inlet  or  superior  strait  of  the  pelvis  varies  considerably  in  accord- 
ance with  the  point  of  view  selected,  but  if  the  eye  of  the  observer  is  placed 
in  the  probable  position  of  the  axis  of  the  child  at  term,  it  will  be  seen  that 
the  shape  of  the  inlet  is  approximately  circular  (Fig.  215). 


THE  MECHANISM   OF  LABOR.  441 

It  must  be  remembered  that  the  presence  of  the  soft  parts  somewhat  alters 


Fig.  216.— Lateral  view  of  the  pelvis,  showing  superior  and  inferior  straits  (one-third  natural  size). 

the  shape  of  the  brim.     The  importance  of  this  fact,  however,  is  lessened  by 


Fig.  217.— Pelvis  seen  from  above,  showing  diameters  of  brim  (one-third  natural  size). 

the  fact  that  the  vessels,  the  connective  tissues,  and  the  rectum,  as  well  as  the 


442  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

psoas-iliacus  muscles,  which  together  form  the  only  important  soft  parts  in  the 
inlet,  are  concentrated  in  the  sacro-iliac  notches,  where  the  space  is  already 
most  abundant  and  where  its  decrease  is  of  least  importance. 

The  dimensions  of  each  of  the  straits  are  determined  by  measuring  the 
antero-posterior,  the  transverse,  and  the  two  oblique  diameters.  The  antero- 
posterior, or,  as  it  is  more  commonly  termed,  the  conjugate,  diameter  of  the 
superior  strait  (Fig.  217)  extends  from  the  upper  border  of  the  symphysis 
pubis  to  the  promontory  of  the  sacrum  ;  its  normal  length  is  11.5  centimeters 
(4i  inches).  A  little  less  than  half  an  inch  from  the  upper  border  of  the 
symphysis  pubis  is  found  a  point  which,  owing  to  the  thickness  of  the  pubic 
bone,  is  decidedly  nearer  to  the  promontory  than  the  upper  border  itself. 
From  the  promontory  to  this  point  the  distance  is  11  centimeters  (about  4J 
inches),  and  this  is  called  the  "obstetrical"  diameter  or  true  conjugate. 

The  greatest  transverse  diameter  of  the  superior  strait  averages  13.5  centi- 
meters (5|  inches)  in  length  ;  this  is  the  diameter  referred  to  whenever  the 
transverse  diameter  of  the  superior  strait  is  mentioned.  This  diameter  lies, 
however,  so  far  back  in  the  pelvis — that  is,  so  near  the  promontory  (Fig.  217) 
— that  it  can  never  be  occupied  by  any  of  the  diameters  of  the  fetal  head. 
The  transverse  diameter,  which  could,  in  fact,  be  occupied  by  the  fetal  head, 
lies  some  distance  anterior  to  this,  and  is  so  much  shorter  as  to  be  of  little 
importance,  being,  in  fact,  less  than  are  the  oblique  diameters.  In  point  of 
fact,  the  head  never  enters  a  normal  pelvis  transversely,  and  the  transverse 
diameter  is  therefore  measured  merely  as  a  means  of  comparing  one  pelvis 
with  another. 

The  oblique  diameters  extend  from  the  ilio-pectineal  eminences  to  the  sacro- 
iliac articulations  ;  their  length  is  12.75  centimeters  (about  5  inches).  Since  the 
terms  right  and  left  oblique  diameter  are  differently  used  by  different  author- 
ities, it  seems  best  to  distinguish  these  diameters  as  the  first  and  second 
oblique  diameters  of  the  inlet,  in  accordance  with  the  frequency  of  their 
importance  in  the  mechanism  of  labor;  the  first  being  that  which  extends  from 
the  left  ilio-pectineal  eminence  to  the  right  sacro-iliac  synchondrosis. 

The  inferior  strait  is  bounded  by  the  subpubic  ligament,  the  descending 
rami  of  the  pubes,  the  rami,  tuberosities,  and  spines  of  the  ischia,  the  sacro- 
sciatic  ligaments,  and  the  coccyx.  Its  shape,  when  looked  at  in  the  direction 
of  its  axis,  is  that  of  a  lozenge  whose  anterior  sides  are  formed  of  the  pubic 
and  ischiatic  rami,  while  the  posterior  are  made  up  of  the  sacro-sciatie  liga- 
ments.* When  looked  at  from  a  point  somewhat  anterior  to  the  line  of  its 
axis,  it  is  seen  to  present  a  roughly  triangular  shape ;  but  when  we  remember 
that  the  sacro-sciatic  ligaments  become  very  distensible  during  labor,  and  that 
the  softening  of  the  sacro-iliac  and  sacro-coccygeal  articulations  that  occurs 

*  Owing  to  the  projection  downward  of  the  tuberosities  of  the  ischia,  it  will  be  seen  that 
the  surface  of  the  inferior  strait  is  bent  upon  itself  to  form  an  external  convexity  (Fig.  218). 
For  practical  purposes  it  is,  however,  convenient  to  neglect  this  bend,  and  to  deal  with  the 
inferior  strait  as  though  it  did,  in  truth,  lie  in  a  plane  between  the  tip  of  the  coccyx  and  the 
subpubic  ligament. 


THE   MECHANISM    OF  LABOR. 


443 


during  pregnancy  permits  of  a  considerable  movement  of  these  bones  upon 
each  other,  it  will  be  seen  that  when  the  soft  parts  of  the  inferior  strait  are 


Fig.  218.— Lateral  view  of  the  pelvis,  showing  external  convexity  of  the  inferior  strait. 

distended  by  the  head,  its  aspect  from  either  position  will  be  that  of  an  ovate 
or  egg-shaped  orifice  (Fig.  219). 

The  antero-posterior  diameter  of  the  inferior  strait  extends  from  the  lower 
border  of  the  symphysis  to  the  extremity  of  the  coccyx.  Its  length  in  the 
non-parturient  state  is  9  centimeters  (about  3J  inches),   but  when  the  move- 


Fig.  219.— View  of  distended  outlet.    The  dotted  lines  show  the  possible  position  of  the  sacro-sciatic 
ligament  and  the  consequent  increase  in  the  transverse  diameter  during  extreme  distention. 

ments  of  distention  spoken  of  above  are  fully  effected,  the  length  of  this  diam- 
eter is  increased  to  11  centimeters  (4-f  inches),  or  perhaps  even  to  12  centime- 
ters (4|  inches). 

The  transverse  diameter,  which  is  drawn  between  the  inner  borders  of  the 
tuberosities,  measures  11  centimeters  (4|  inches),  and  it  is 'the  only  unyield- 


444 


AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 


ing  diameter  of  the  inferior  strait.  The  divergent  direction  of  the  tuberosities 
makes  it  possible,  however,  for  the  transverse  diameter  of  the  head  to  corre- 
spond with  a  much  wider  transverse  diameter  of  the  outlet  whenever  the  con- 
ditions of  the  case  permit  the  parietal  protuberances  to  occupy  a  position  pos- 
terior to  the  tuberosities  (Fig.  219). 

The  oblique  diameters  are  manifestly  rendered  unimportant  by  the  uncer- 
tainty as  to  their  length,  the  result  of  the  elasticity  of  the  sacro-sciatic 
ligaments. 

The  excavation,  which  is  bounded  by  the  inferior  and  superior  straits,  com- 
prises all  that  portion  of  the  pelvis  lying  between  them.  The  backward  curve 
of  the  bodies  of  the  sacral  vertebrae  and  the  straightness  and  shortness  of  the 
anterior  wall  of  the  pelvis  render  the  excavation  much  more  roomy  in   an 


Fig.  220.— Diagram  showing  a  division  of  the  lateral  wall  of  the  excavation  into  seetio 
with  their  mechanical  functions. 


i  in  accordance 


antero-posterior  direction  than  is  either  of  the  straits,  and  this  increase  of 
space  is,  of  course,  greatest  in  the  middle  portion  of  the  excavation.  The 
oblique  diameters  are  correspondingly  increased  for  the  same  reason,  and, 
indeed,  in  the  middle  of  the  excavation  they  are  often  longer  than  any 
of  the  diameters  of  a  small  fetal  head — a  fact  which  is  sometimes  of  import- 
ance in  the  mechanism  of  posterior  positions  of  the  vertex  and  of  presentations 
of  the  face. 

If  the  transverse  diameters  of  the  excavation  were  similarly  ample,  this 
portion  of  the  pelvis  would  be  devoid  of  obstetrical  interest ;  but  this  is  far 
from  true.  The  transverse  diameter  of  the  excavation  is  at  one  point  the 
smallest  and  also  one  of  the  most  rigid  diameters  of  the  whole  pelvis,  and  the 
importance  of  the  anatomy  of  the  lateral  walls  of  the  excavation  is  so  great 
that  its  comprehension  is  the  key-note  to  the  whole  subject  of  obstetrical  mech- 
anism.    The  anatomy  of  the  lateral  walls  is  so  difficult  of  description  that  it 


THE  MECHANISM   OF  LABOR.  445 

is  possible  to  comprehend  it  only  by  means  of  a  subdivision  of  the  lateral 
walls  of  the  excavation  into  three  parts  (Fig.  220) :  An  upper  portion  (A,  Fig. 
220),  which  is  roughly  triangular  in  shape ;  a  second  portion  (B),  which  lies 
below  and  in  front  of  the  first;  and  a  third  portion  (C),  which  lies  below  and 
behind  the  first. 

Portion  A  is  composed  throughout  of  unyielding  bone.  In  its  upper  part 
its  surface  is  smooth  and  very  uniformly  curved.  The  transverse  diameter  of 
the  pelvis  at  this  point  is  the  ample  transverse  diameter  of  the  superior  strait. 
The  oblique  lines  drawn  through  the  anterior  edge  of  this  portion  upon  one 
side  of  the  pelvis  and  through  the  posterior  edge  of  the  corresponding  portion 
upon  the  other  side  are  likewise  ample,  and,  indeed,  vary  but  little  from  this 
same  length  (5^  inches).  In  its  lower  part  portion  A  of  the  lateral  wall 
inclines  inward  to  its  termination  in  the  rigid  ischial  spines,  between  the  points 
of  which  the  smallest  diameter  of  the  pelvis  is  found — a  diameter  so  small 
as  to  be  practically  impassable  by  the  biparietal  and  suboccipito-bregmatic 
diameters  of  a  full-sized  head. 

Portion  B  of  the  lateral  walls  of  the  excavation  has  but  little  rigid 
bone  in  its  composition.  The  ileo-pubic  ramus  Avhich  forms  its  upper 
portion  is  as  smoothly  and  uniformly  curved  as  the  rest  of  the  brim 
of  the  pelvis.  Its  middle  part  is  made  up  mainly  of  the  membranous 
coverings  of  the  foramen  ovale,  that  are  covered  by  the  obturator  muscle, 
and  at  the  time  of  term,  like  all  the  other  ligaments  and  fascial  coverings 
of  the  pelvis,  are  more  elastic  than  in  the  non-parturient  state.  When 
these  muscles  and  fasciffi  are  put  upon  the  stretch  by  the  pressure  of  the  pre- 
senting part  during  its  descent,  their  recession  converts  portion  B  of  the 
lateral  wall  into  a  shallow  spiral  groove,  with  bony  edges  and  a  soft  floor, 
which  deepens  as  it  descends  and  turns  forward.  The  ischio-pubic  ramus, 
which  forms  the  floor  of  the  lower  part  of  portion  B,  is  here  so  curved  (lat- 
erally outward)  as  to  lend  itself  readily  to  the  continuation  of  this  groove. 

Portion  C  has  a  bony  edge  composed  of  the  posterior  border  of  the  ischium 
and  the  lateral  edge  of  the  sacrum  and  coccyx,  but  it  is  made  up  mainly  of 
the  very  elastic  sacro-sciatic  ligaments  and  the  pyramidal  muscle.  When  these 
ligaments  and  muscles  are  put  upon  the  stretch  during  the  descent  of  the  head, 
portion  Oof  the  lateral  wall  is  converted,  like  portion  B,  into  a  spiral  groove 
which  deepens  as  it  descends  and  turns  forward. 

When  the  rigidity  of  portion  A  and  the  yielding  nature  of  portions 
B  and  C  are  considered  in  connection  with  the  fact  that  even  in  the  bony 
pelvis  the  foramen  ovale  and  the  sacro-sciatic  notches  are  regions  of  recession 
separated  from  each  other  by  the  projecting  ischial  spines,  it  will  be  seen  that 
when  distended  by  pressure  from  within,  the  lateral  walls  of  the  excavation 
may  be  considered  as  consisting,  for  mechanical  purposes,  of  two  deep  grooves 
separated  from  each  other  by  a  prominent  ridge  of  unyielding  bone  (Fig.  221). 
The  anterior  of  these  grooves  pursues  a  spiral  course  downward  and  forward 
from  the  anterior  end  of  the  oblique  diameter  at  the  brim,  to  end  under  the 
pubic  arch  at  the  inferior  strait.     The  posterior  groove  pursues  a  similar 


446 


AMEBICAX    TEXT-BOOK    OF    OBSTETRICS. 


spiral  course  downward  and  forward  from  the  posterior  end  of  the  other 
oblique  diameter  at  the  brim,  to  end  in  the  same  point  at  the  outlet. 


Fig.  221.— Sections  of  the  pelvis,  showing  the  lateral  grooves  and  the  bony  ridge  which  separates  them : 
A,  sagittal  section.  The  lines  b,  c,  d,  e,  indicate  the  horizontal  planes  through  which  the  cross-sections 
b,  c,  d,  e,  are  taken.  The  shaded  portions  of  the  figure  indicate  the  spiral  grooves,  the  depth  of  the 
groove  being  deepest  where  the  shading  is  darkest.  B,  cross-section,  showing  the  nearly-uniform  curve 
of  the  unbroken  bony  circumference  of  the  superior  strait.  C,  cross-section,  showing  the  bony  ischium 
(A,  Fig.  220)  separating  the  distensible  foramen  ovale  (B,  Fig.  220)  and  sacro-sciatic  notch  (C,  Fig.  220).  D, 
cross-section  through  the  ischial  spines,  which  here  emphasize  deflection  inward  of  the  bony  ridge  (A, 
Fig.  220).  E,  cross-section  near  the  inferior  strait.  The  posterior  half  is  distensible,  and  in  the  anterior 
half  the  bony  descending  ramus  of  the  pubes  curves  outwardly  to  continue  the  curve  formed  by  the 
yielding  tissues  which  cover  in  the  foramen  ovale,  as  seen  in  the  sections  C  and  D. 

The  oblique  diameters  drawn  toward  the  bottom  of  the  anterior  groove 


THE  MECHANISM   OF  LABOR.  447 

upon  one  side  and  the  bottom  of  the  posterior  groove  upon  the  other  side  are 
throughout  the  pelvis  ample  for  the  passage  of  any  of  the  diameters  of  the 
fetal  head  except  the  occipito-frontal  and  the  occij>ito-mental.  Should  any 
rounded  body  be  started  at  the  upper  end  of  either  of  these  grooves,  and  be 
forced  downward  by  a  vis-a-tergo  under  the  influence  of  a  constant  intrapelvic 
pressure,  it  must  necessarily  follow  the  path  of  least  resistance — that  is,  the 
course  of  the  groove  in  which  it  started — to  end  its  course  under  the  pubic 
arch  at  the  outlet.  The  importance  of  these  considerations  will  be  apparent 
when  the  section  on  the  Mechanism  of  the  Second  Stage  of  Labor  is  reached. 

Infrapelvic  Portion. —When  the  soft  parts  below  the  inferior  strait  are 
distended  by  the  head,  they  include  a  hood-shaped  space  of  considerable  size, 
bounded  upon  its  upper  border  by  the  edge  of  the  pubic  arch,  the  tuberosities 
of  the  ischia,  and  the  lower  edge  of  the  sacro-sciatic  ligaments,  and  upon  its 
other  or  inferior  border  by  the  orifice  of  the  distended  vagina.  Its  anterior 
wall  is  from  a  quarter  to  half  an  inch  in  length.  Its  posterior  wall,  when 
fully  distended,  is  from  6  to  10  centimeters  (2J  to  4  inches)  in  length. 

When  the  head  has  wholly  escaped  from  the  inferior  strait  it  occupies  an 
elastic  canal  composed  wholly  of  soft  parts  and  having  but  one  mechanical 
function — an  elasticity  which  keeps  the  head  constantly  in  contact  with  the 
edge  of  the  pubic  arch. 

The  Parturient  Canal  as  a  "Whole. — The  parturient  canal  (Fig.  214)  con- 
sists functionally  of  two  portions,  an  ovate  reservoir  formed  by  the  uterine 
cavity  and  the  false  pelvis,  and  a  curved  passage  which  extends  downward 
and  forward  from  the  lower  opening  of  the  reservoir.  This  passage  possesses 
an  irregularly  cylindrical  shape  which  has  classically  been  likened  to  the  curve 
of  a  ram's  horn.  The  anterior  wall  is  much  shorter  than  the  posterior.  If 
both  the  anterior  and  posterior  walls  are  divided  into  an  equal  number  of 
equal  parts,  and  planes  are  drawn  between  each  pair  of  these  points  (Fig.  222), 
a  curved  line  passing  through  the  centre  of  each  of  these  planes  forms  what  is 
known  as  the  axis  of  the  pelvic  canal;  if  this  curved  line  is  continued  forward, 
it  will  reach  the  abdomen  of  the  mother  at  about  the  situation  of  the  umbilicus 
in  the  non-parturient  state.  This  prolongation  of  the  pelvic  axis  is  known 
as  the  curve  of  Cams. 

The  centre  of  any  body  passing  through  the  pelvic  canal  must  travel  through 
a  path  closely  approximate  to  this  curved  axis.  Were  the  pelvic  canal  exactly 
cylindrical  and  the  fetal  head  exactly  spherical,  the  mechanism  of  labor  would 
be  limited  to  an  observation  of  the  above-related  fact;  but  in  reality  the  irreg- 
ularities in  the  contour  of  the  pelvic  canal  and  the  corresponding  irregularities 
in  the  shape  of  the  fetal  head  are  matters  of  the  greatest  importance.  It  will 
be  remembered  that  although  the  transverse  diameter  of  the  superior  strait  is 
nominally  the  greatest,  yet  the  rapid  convergence  of  the  ilio-pectineal  lines  as 
they  stretch  forward  renders  the  length  of  the  practicable  transverse  diameter 
in  fact  less  than  that  of  the  oblique  diameters,  so  that  any  ovate  body  presented 
to  the  inlet  of  the  pelvis  will  tend  to  enter  the  brim  in  the  oblique  diameter. 

At  the  inferior  strait  the  transverse  diameter  is  the  narrowest  of  the  whole 


448 


A3IEBICAN   TEXT-BOOK    OF    OBSTETRICS. 


pelvis,  and,  since  the  oblique  diameters  at  the  moment  of  delivery  are  shorter 
than  the  distended  conjugate,  any  ovate  body  which  attempts  to  pass  the  outlet 
will  do  so  most  readily  if  its  long  diameter  corresponds  with  the  antero-posterior 
diameter  of  the  inferior  strait.     It  is  therefore   evident  that  the  process  of 


Sagittal  section  of  the  pelvis,  showing  the  pelvic  axis  and  the  curve  of  Cams. 


labor  will  most  easity  be  accomplished  by  the  occurrence  of  a  rotation  of  the 
longest  diameter  of  the  presenting  parts  from  an  oblique  position  at  the  supe- 
rior straight  to  an  antero-posterior  position  at  the  outlet ;  and,  in  point  of  fact, 
the  mechanical  relations  which  lead  up  to  this  rotation  lie  at  the  bottom  of 
the  whole  subject  of  the  mechanism  of  labor. 

It  is  to  be  noted  that  when  the  woman  is  in  the  erect  position  the  axis  of 
the  superior  strait*  forms  an  angle  of  about  30°  with  the  horizon;  that  in 
the  same  position  of  the  woman  the  axis  of  the  inferior  strait  is  directed 
downward  and  a  little  forward;  and  that  the  axis  of  the  vaginal  outlet  of 
the  distended  parturient  canal  looks  almost  directly  forward  and  but  very 
slightly  downward  (Fig.  222). 

Differences  between  the  Male  and  the  Female  Pelvis. — It  is  important 
that  the  obstetrician  should  clearly  understand  the  normal  characteristics  of 
the  female  pelvis  in  contradistinction  to  those  of  the  masculine  form,  because 
the  approaches  to  a  masculine  type — which  are  not  uncommon  and  may  occur 

*  A  line  drawn  from  the  centre  of  the  superior  strait  in  a  direction  perpendicular  to  its 
plane. 


THE   MECHANISM   OF  LABOR. 


449 


in  any  portion  of  the  pelvis — are  not  unimportant  as  a  cause  of  dystocia  and 
of  alterations  in  the  mechanism  of  labor.  The  differences  between  the  male 
and  the  female  pelvis  will  be  rendered  most  easily  familiar  by  the  use  of  a 
series  of  figures  showing  respectively  the  shapes  of  the  superior  strait,  of  the 


Fig.  223.— Male  pelvis  viewed  in  the  axis  of  the  brim. 

antero-posterior  curve  of  the  sacrum  and  the  pubic  arch,  and  of  the  inferior 
strait  in  the  masculine  and  feminine  types. 

Superior  Strait. — In  the  male  the  sacrum  is  narrow,  the  promontory  en- 
croaches deeply  into  the  brim,  the  iliac  crests  are  comparatively  erect,  and  the 
interior  concavity  of  the  anterior  portion  of  the  ilio-pectineal  line  is  but  little 


Fig.  224.— Female  pelvis  viewed  in  the  axis  of  the  brim. 

marked  (Fig.  223).     The  shape  of  the  inlet  is  thus  angular  and  strongly  cor- 
date as  compared  with  that  of  the  female  pelvis  (Fig.  224). 

Antero-posterior  Section  of  the  Pelvis. — In  the  male  the  sacrum  is  lono-  and 

29 


450 


AMEBIC  AX   TEXT-BOOK    OE    OBSTETBICS. 


its  upper  portion  is  nearly  straight,  while  the  lower  part  of  this  bone  and  its 
continuation,  the  coccyx,  are  bent  sharply  forward.  The  symphysis  and  the 
adjacent  portions  of  the  descending  rami  are  long  and  erect.  (Fig.  227).    In  the 


Fig.  225.— Male  pelvis  seen  from  the  front. 


female  (Fig.  228)  the  sacrum  is  shorter,  its  general  direction  is  more  distinctly 
downward  and  backward,  its  upper  portion  is  much  more  concave  from  above 
downward,  and  the  antero- posterior  curve  is  throughout  more  uniform  than  in 


Fig.  226.— Female  pelvis  seen  from  the  front  (one-third  natural  size). 

the  male.  The  symphysis  is  short,  and  the  wider  pubic  arch,  shortly  to  be 
spoken  of,  decreases  the  importance  of  the  descending  rami  in  the  formation 
of  the  anterior  wall. 

Inferior  Strait. — In  the  male  (Fig.  225)  the  angle  of  the  pubic  arch  meas- 


THE  MECHANISM   OF  LABOR. 


451 


ures  from  75°  to  80°.  The  anterior  wall  of  the  pelvis — that  is,  the  dis- 
tance between  the  symphysis  and  the  tuberosities — is  long  as  compared  with 
the  pelvis  of  the  female  (Fig.  226),  in  which  pelvis  the  sides  of  the  pubic 
arch  form  an  angle  of  from  90°  to  100°,  and  the  entire  depth  of  the  pelvis  is 
much  diminished.  The  backward  recession  of  the  tip  of  the  sacrum  and  the 
coccyx,  together  with  the  increased  distance  between  the  tuberosities,  greatly 


Fig.  227.— Diagrammatic  anteroposterior  section 
of  male  pelvis. 


223.  —Diagrammatic  antero-posterio 
of  female  pelvis. 


increases  the  size  of  the  inferior  strait  in  the  female  (Fig.  224)  as  compared 
with  the  male  (Fig.  223).  There  is  a  greater  relative  distance  between  the 
acetabula,  and  their  surfaces  are  directed  somewhat  obliquely  to  the  front. 
This  situation  of  the  acetabula  is  decidedly  unfavorable  to  the  function  of  the 
hip-joints  in  locomotion,  and  it  accounts  for  the  greater  proximity  of  the  knees 
in  women  and  for  the  characteristic  difference  between  their  gait  and  that  of 
men,  whose  pelvic  bones  are  designed  for  locomotion  alone. 

The  Fetus. 

The  head  of  the  new-born  child  is,  proportionately  to  its  body,  so  much 
larger  than  that  of  the  adult,  and  the  body  is  proportionately  so  much  the 
more  compressible,  that  the  head  is  in  most  cases  the  only  part  of  the  body 
that  affords  any  considerable  mechanical  obstacle  to  the  passage  of  the  fetus 
through  the  parturient  canal.  From  its  comparative  incompressibility  it  is, 
moreover,  the  part  which  most  nearly  retains  its  normal  shape  throughout 
labor,  and  it  is  therefore  in  the  passage  of  the  head  that  the  mechanical  pro- 
cesses of  labor  are  most  plainly  marked  and  most   important. 

From  the  foregoing  considerations  it  is  at  once  apparent  that  a  thorough 
familiarity  with  the  dimensions  and  shape  of  the  fetal  head  and  with  the 
changes  it  undergoes  during  labor  is  a  necessary  preliminary  to  the  compre- 
hension of  the  principles  of  obstetric  mechanism.     Some  familiarity  with  the 


452 


AMERICAN    TEXT-BOOK   OF    OBSTETRICS. 


shape  and  dimensions  of  the  remainder  of  the  fetus  in  the  attitude  it  ordi- 
narily assumes,  though  less  often  of  importance,  is  nevertheless  essential. 

The  Fetal  Head. — The  head  is  obstetrically  divided  into  two  portions,  the 
face  and  the  cranium. 

The  face  is  much  smaller  in  proportion  to  the  cranium  than  that  of  the 
adult,  and  is  of  but  little  importance  in  normal  labors.  It  is,  however,  well 
to  remember  that  the  face  is  made  up  of  the  most  solid  and  incompressible 
bones  which  enter  into  the  composition  of  the  head,  and  that  its  configuration 
is  altered  but  little,  if  at  all,  by  the  processes  of  labor. 

The  cranium  or  brain-case  is  to  be  divided  for  purposes  of  description  into 
two  portions,  the  base  and  the  vault  of  the  skull.  The  base  is  formed  by  the 
basilar  portion  of  the  occipital  bone,  the  petrous  portions  of  the  temporal 
bones,  the  sphenoid  and  ethmoid,  and  the  orbital  processes  of  the  frontal 
bones.  These  bones,  even  at  birth,  are  firmly  united,  and  they  form  a  com- 
paratively small  but  almost  totally  incompressible  mass.  The  vault  is  made 
up  of  the  parietal  bones  and  the  squamous  portions  of  the  occipital,  temporal, 
and  frontal  bones.  These  bones  are  all  wide,  flat,  and  slightly  curved.  The 
squamous  portion  of  the  occipital  bone  is  attached  to  the  basilar  portion  by  a 
band  of  fibro-eartilaginous  tissue  which  permits  of  quite  free  motion  between 
the  two  portions.  All  the  bones  of  the  vault  are  united  at  their  edges  by 
membranous  commissures  formed  of  the  dura  mater  and  the  unossified  external 
periosteum.  The  vault  of  the  cranium,  though  much  larger  than  the  base  of 
the  skull,  differs  from  the  base  in  its  possession  of  compressibility  and  of  a 
marked  capacity  for  alteration  of  shape  under  the  moulding  influences  of  the 
constant  pressure  of  labor.  It  must  be  remembered,  however,  that  different 
heads  present  very  different  degrees  of  ossification  at  the  time  of  birth,  and, 
indeed,  vary  widely,  from  cases  in  which  the  flat  bones  are  so  slightly  ossified 
as  readily  to  be  bent  by  the  pressure  of  the  finger,  and  in  which  the  mem- 
branous intervals  are  extremely  wide  and  well  marked,  up  to  cases  in  which 

the  ossification  and  union  of  the  bones 
are  so  far  advanced  as  to  reduce  the 
compressibility  of  the  skull  to  a  min- 
imum of  small  practical  value. 

The  Sutures  and  the  Fontanelles. — 
The  membranous  lines  of  union  between 
the  contiguous  bones  of  the  vault  are 
known  as  sutures,  and  at  the  points 
where  more  than  two  bones  meet  these 
sutures  commonly  widen  out  to  mem- 
branous spaces  known  as  fontanelles  (Fig.  229).  The  sutures  are  distinguished 
by  the  following  names:  That  between  the  frontal  bones  is  the  frontal;  that 
between  the  frontal  and  parietal  bones  is  the  coronal;  that  between  the  parie- 
tals  is  the  sagittal;  and  that  which  separates  the  squamous  portions  of  the 
occipital  from  the  two  parietals  is  the  lambdoidal  suture. 

At  the  point  where  the  frontal  and  parietal  bones  come  together  the  frontal, 


Fig.  229.— Diagrams  of  the  fontanelles :  A,  ante^ 
rior;  B,  posterior;  C,  lateral. 


THE  MECHANISM   OF  LABOR.  453 

sagittal,  and  coronal  sutures  meet  in  a  membranous  space  or  fontanelle  which 
is  rhomboidal  in  shape  and  is  ordinarily  of  considerable  extent.  This  space 
is  known  as  the  anterior  or  large  fontanelle,  and  sometimes  as  the  bregma  (PI. 
28,  Fig.  2).  Of  its  four  sides,  the  two  anterior  are  usually  the  longer,  and 
when  this  difference  is  well  marked  the  resulting  fontanelle  may  more  properly 
be  said  to  assume  the  shape  of  an  Indian  arrow-head  (Fig.  229,  a). 

The  junction  of  the  sagittal  and  lambdoidal  sutures  at  the  point  where  the 
occipital  and  parietal  bones  meet  forms  a  small  triangular  space,  known  as  the 
posterior  occipital,  or  small  fontanelle  (PI.  28,  Fig.  3).  In  well-ossified  heads 
this  space  is  frequently  small  or  wanting,  and  the  posterior  fontanelle  is  then 
represented  only  by  the  junction  of  the  three  sutures.  It  is  to  be  remembered, 
moreover,  that  when  the  bones  are  closely  crowded  together  by  the  pressure 
of  severe  labor,  either  fontanelle,  however  well  marked,  may  be  partially 
or  wholly  effaced  for  the  time  by  an  overlapping  of  the  edges  of  the  bones 
which  bound  it.  Exceptionally,  a  locally  defective  ossification  along  the  edges 
of  the  bones  may  result  in  the  production  of  either  Wormian  bones  or  false 
fontanelles,  both  of  which  are  most  common  in  the  course  of  the  sagittal 
suture,  and  which  may  result  in  considerable  confusion  of  diagnosis  if  the 
possibility  of  their  existence  is  not  borne  in  mind.* 

Dimensions  of  the  Fetal  Head. — The  size  of  the  fetal  head  at  term 
varies  greatly  with  the  size  of  the  individual  fetus,  but,  however  great  this 
variation  ma}'  be,  the  relative  proportions  between  the  different  parts  of  the 
head  remain  approximately  constant,  and  for  the  sake  of  clearness  it  is  usual, 
in  the  discussion  of  general  principles,  to  ignore  this  variation  of  size  and  to 
use  as  the  basis  of  argument  the  dimensions  of  the  average  head.  The  diam- 
eters that  have  been  found  most  useful  in  the  description  of  the  head  are  as 
follows :  The  anteroposterior  diameters — the  occipito-mental,  the  occipito- 
frontal, the  suboccipito-bregmatic ;  the  transverse  diameters — the  biparietal,  the 
bitemporal,  and  the  bimastoid  ;  the  vertical  diameters — the  fronto-mental  and 
the  cervico-bregmatic. 

Anteroposterior  Diameters. — The  occipito-mental  diameter  (PI.  28,  Fig.  1) 
is  drawn  from  the  chin  to  the  most  distant  portion  of  the  occiput.  The  occipito- 
frontal (PI.  28,  Fig.  1)  is  drawn  from  the  point  of  union  of  the  supraorbital 
ridges  to  that  portion  of  the  occiput  which  is  most  distant  from  them.  The 
suboccipito-bregmatic  (PI.  28,  Fig.  1)  is  drawn  from  the  point  of  junction 
between  the  occiput  and  the  neck  to  the  centre  of  the  anterior  fontanelle. 

Transverse  Diameters. — The  biparietal  diameter  (PI.  28,  Figs.  2,  4)  is  drawn 
from  the  apices  of  the  biparietal  protuberances — namely,  through  that  portion 

*  It  is  well  to  bear  in  mind,  in  addition  to  the  anterior  and  posterior  fontanelles,  the  occa- 
sional existence  of  a  third,  the  lateral  fontanelle.  This  fontanelle  is  present  only  in  poorly-ossi- 
fied heads,  and  when  present  is  found  at  the  junction  of  the  occipital,  parietal,  and  temporal 
bones,  near  the  base  of  the  mastoid  process  and  behind  the  ear.  The  lateral  fontanelle  may 
sometimes  be  mistaken  for  the  bregma  unless  carefully  observed.  It  is  four-sided,  but  is  irregu- 
lar in  shape  (Fig.  229,  c).  It  may  be  said  that  the  mastoid  process  feels  like  the  side  of  a  large 
canine  tooth  imbedded  in  the  temporal  bone.  It  is  usually  recognizable,  and  it  is  sometimes  a 
valuable  point  in  the  diagnosis  of  this  region  of  the  skull. 


454  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

of  the  skull  at  which  the  lateral  surfaces  are  most  widely  distant  from  each 
other ;  the  bitemporal  (PI.  28,  Figs.  2,  4)  extends  transversely  between  the 
most  distant  portions  of  the  coronal  sutures ;  the  bimastoid  extends  between 
the  mastoid  processes  at  the  base  of  the  skull.  To  these  diameters  is  some- 
times added  a  less  important  diameter,  that  lying  between  the  base  of  the 
zygomatic  processes,  the  bizygomatic. 

Vertical  Diameters. — The  fronto-mental  diameter  (PL  28,  Figs.  1,  4)  extends 
from  the  chin  to  the  upper  part  of  the  forehead  ;  in  the  absence  of  any  dis- 
tinctive point  of  origin  at  its  upper  extremity,  as  well  as  from  its  small  size,  it 
is  of  but  little  importance.  The  cervico-bregmatic  (PI.  28,  Fig.  1)  is  drawn 
between  the  junction  of  the  neck  and  the  chin  arid  the  centre  of  the  anterior 
fontanelle. 

The  lengths  of  the  several  diameters,  as  obtained  by  Tarnier  and  Chan- 
treuil,  are  given  as  follows: 

Centimeters.    Inches. 

Occipitomental  diameter 13  =  5J- 

Occipito-frontal         "  11.5  =  4J- 

Suboccipito-bregmatic  diameter 9.5  =  3J 

Biparietal  diameter 9.5  =  3f 

Bitemporal  diameter 8  =  3} 

Bimastoid  diameter 7.5  =  3 

Fronto-mental  diameter 8  =  Z\ 

Cervico-bregmatic  diameter 9.5  =  3| 

These  diameters  may  be  divided  into  classes  in  two  ways:  (1)  by  their  com- 
pressibility, and  (2)  by  the  degree  of  difficulty  with  which  they  may  be  expected 
to  pass  the  pelvis.  The  compressibility  of  the  fetal  head  as  a  whole  is  not  only 
a  very  variable  factor,  but  the  different  parts  of  the  same  head  vary  widely  in 
both  the  ease  and  the  safety  with  which  compression  can  be  applied  to  them. 

The  biparietal  and  bitemporal  diameters  are  safely  and  easily  compressible. 
The  suboccipito-bregmatic,  oceipito-frontal,  and  occipito-mental  diameters  are 
almost  equally  compressible,  but  the  degree  of  danger  to  the  fetus  that  com- 
pression of  these  diameters  involves  is  vastly  greater  than  is  the  case  with 
the  biparietal  and  bitemporal  diameters ;  and  with  oblique  compression  the 
degree  of  danger  increases  as  the  direction  of  the  force  approaches  to  the 
antero-posterior  diameters.  The  bimastoid  and  bizygomatic  diameters  are  for 
practical  purposes  totally  incompressible. 

The  Relative  Value  of  the  Diameters  of  the  Head  as  Compared  with 
the  Diameters  of  the  Pelvis. — It  will  be  observed  that  the  lengths  of  the 
suboccipito-bregmatic  and  biparietal  diameters  are  nearly  equal,  so  that  a  cross- 
section  of  the  head  through  these  diameters  (Fig.  230,  a)  is  very  nearly  circu- 
lar ;  and  from  this  fact  and  from  their  size  this  cross-section  is  capable  of  pass- 
ing any  diameter  of  the  pelvis*  when  presented  to  it  in  any  obstetrical  posi- 
tion. Since  this  is  the  cross-section  which  is  always  presented  to  the  pelvis  by 
well-flexed  heads,  the  study  of  position  would  be  of  little  importance  if  the  ex- 
istence of  flexion  could  always  be  depended  upon  and  if  the  remainder  of  the 
*  Except  that  between  the  spines  and  the  ischia. 


LABOR. 


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Occipital  Protuberance 


Fetal  Head  :  1.  Fetal  skull  seen  from  the  side ;    2.  Fetal  skull  seen  from  above :    3.  Fetal  skull  seen  from 
behind;    4.  Fetal  skull  seen  from  in  front-showing  sutures,  fontanelles,  and  diameters. 


THE    MECJTAXJSM    OF   LABOR. 


455 


head  could  be  neglected  ;  but  two  factors  in  labor  equally  contribute  to  render 
this  cross-section  of  the  head  by  no  means  the  only  one  which  must  be  con- 
sidered. In  the  first  place,  we  must  be  prepared  to  consider  the  mechanism 
of  brow  and  face  cases,  and,  in  addition,  those  cases  of  vertex  labor  in  which 
the  flexion  of  the  head  is,  from  one  cause  or  another,  imperfect ;  and,  moreover 
even  in  the  best  vertex  labor  good  flexion  is  seldom  attained  in  the  early  stages 


Fig.  230— Diameters  of  the  fetal  head:  A,  cross-section  of  the  fetal  head  through  the  suboccipito- 
bregmatic  and  biparietal  diameters  ;  B,  eross-section  of  the  fetal  head  through  the  bi parietal  and  occipito- 
frontal diameters;  C,  cross-section  of  the  fetal  head  through  the  biparietal  and  occipito-mental  diam- 
eters ;  D,  cross-section  of  the  fetal  head  through  the  suboccipito-frontal  and  bitemporal  diameters. 

of  engagement  at  the  brim.  Secondly,  even  when  good  flexion  is  present  and 
this  circular  cross-section  is  in  the  inferior  strait  or  excavation,  the  brim  is 
occupied  by  the  frontal  portion  of  the  head  in  combination  with  the  neck — a 
by  no  means  unimportant  factor  in  the  mechanism  of  even  the  most  normal 
cases. 

It  is  therefore  important  to  remember  the  shape  and  dimensions  of  the 
cross-sections,  which  include,  first,  the  biparietal  and  occipitofrontal  diameters 
(Fig.  230,  b)  ;  second,  the  biparietal  and  occipito-mental  diameters  (Fig.  230,  c) ; 
third,  that  which  cuts  the  head  and  neck  through  what  might  be  called  the 
"  suboccipito-frontal"  diameter*  and  the  bitemporal  diameter  (Fig.  230,  d).  If 
the  diameters  of  these  cross-sections  be  compared  with  those  of  the  pelvis,  it 
will  be  seen  that  all  the  transverse  diameters  are  capable  of  an  easy  passage 
through  any  of  the  diameters  of  the  pelvis.  The  occipito-frontal  and  sub- 
occipito-frontal are  too  large  to  pass  any  of  the  conventional  f  diameters  except 
the  oblique  diameters  at  the  superior  strait  and  the  distensible  antero-posterior 

*  Approximately  the  cervico-bregmatic  plus  the  thickness  of  the  neck. 
t  Those  which  have  names. 


456  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

diameters  of  the  inferior  strait ;  while  the  occipito-mental  is  too  large  even  for 
these,  and  may  consequently  be  regarded  as  an  impracticable  or  impossible 
diameter. 

A  careful  remembrance  of  the  relative  values  of  these  diameters  will  be 
found  of  great  service  in  the  comprehension  of  normal  labor,  and  of  still  more 
value  in  understanding  abnormal  labor. 

The  Articulations  between  the  Head  and  the  Spinal  Column. — The 
articulations  by  which  the  head  is  joined  to  the  trunk  are,  it  will  be  remem- 
bered, the  occipito-atlantoid,  the  atlanto-axial,  and  those  between  the  other 
cervical  vertebrae.  The  occipito-atlantoid  articulation  admits  of  but  little 
motion  except  that  of  extension  and  flexion,  while  even  that  motion,  when 
carried  to  extremes,  is  greatly  assisted  by  a  similar  movement  in  the  other 
cervical  articulations.  So,  too,  the  rotatory  movement  which  alone  is  possible 
in  the  atlanto-axial  joint  is  greatly  assisted  by  the  movements  in  the  other 
articulations  of  the  neck.  The  capacity  for  lateral  flexion  resides  wholly  in 
the  intervertebral  articulations  and  is  limited  by  their  ligaments.  Rotation 
of  the  head  to  either  side  is  safely  possible  only  through  an  arc  of  about  90°  ; 
that  is,  when  the  chin  of  the  fetus  is  in  the  plane  of  the  shoulders  the  limit 
of  safety  in  rotation  has  been  reached.  Antero-posterior  flexion  is  limited 
only  by  contact  between  the  chin  and  the  breast.  Extension  can  be  carried 
to  a  point  at  which  the  occiput  rests  against  the  back  of  the  neck  and  the  chin 
is  in  a  line  with  its  anterior  surface. 

The  Fetal  Body. — The  compressibility  of  the  fetal  trunk  renders  impossible 
and  worthless  any  statement  of  the  absolute  length  of  the  diameters  which  the 
fetal  body  presents  to  the  pelvis  during  labor;  but  the  relative  lengths  of  the 
transverse  and  antero-posterior  diameters  as  compared  with  each  other  is  of 
importance,  and  is  constant  in  at  least  two  parts  of  the  trunk — namely,  in  the 
regions  of  the  shoulders  and  the  hips.  The  transverse  diameter  in  both  these 
regions  is  always  longer  than  the  antero-posterior  diameter. 

The  Shoulders. — The  relation  of  the  shoulders  of  the  infant  to  the  mechan- 
ism of  labor  is  somewhat  altered  by  their  movability.  The  shoulders  may  be 
jjresented  to  any  portion  of  the  pelvis  in  one  of  two  positions  :  First,  they 
may  enter  together,  with  the  line  of  the  clavicles  approximately  at  right  angles 
to  the  spine — that  is,  in  the  position  ordinarily  assumed  by  adults.  Second, 
one  shoulder  may  be  elevated  and  the  other  depressed,  so  that  the  one  enters 
in  advance  of  the  other,  both  clavicles  being  still  approximately  in  the  same 
line,  but  this  line  now  forming  an  oblique  angle  with  that  of  the  vertebral 
column.  In  the  second,  which  is  the  usual  and  normal  position,  the  transverse 
diameter  never  loses  its  superiority  of  length  over  the  antero-posterior  diameter. 
When  both  shoulders  enter  together,  this  superiority  of  the  transverse  diam- 
eter is  always  rendered  somewhat  less  marked  by  the  occurrence  of  a  simul- 
taneous forced  depression  of"  both  clavicles,  and  is  occasionally  so  much 
diminished  as  to  lead  to  interruptions  of  the  mechanism  by  which  the 
delivery  of  the  shoulders  is  normally  accomplished. 

The  Hips. — The  pelvic  bones  of  the  infant  are  sufficiently  rigid  to  prevent 


THE   MECHANISM    OF  LABOR.  457 

any  considerable  moulding  of  the  breech,  and  the  transverse  diameter  of  the 
hips  is  always  considerably  greater  than  the  antero-posterior  diameter  of  the 
same  portion  of  the  body. 

The  Trunk. — The  intermediate  portions  of  the  infant's  trunk  are  so  soft  and 
compressible  that  its  diameters  are  totally  inconstant.  The  shape  of  the  cross- 
section  of  the  trunk  corresponds  with  the  shape  of  that  portion  of  the  pelvis  in 
which  it  lies,  and  even  the  presence  of  the  limbs  in  juxtaposition  with  it 
makes  but  little  difference,  since  its  softness  permits  the  limbs,  under  the  pres- 
sure of  labor,  to  indent  it  at  any  point. 

Diagnosis,  Frequency,  and  Prognosis  of  the  Several  Varieties 
of  Labor. 

Diagnosis.* — In  obstetric  diagnosis  we  are  furnished  with  two  methods  of 
examination  of  almost  equal  importance — namely,  examination  of  the  abdomen 
and  examination  of  the  vagina — which  must  be  described  separately. 

The  abdominal  examination  must  be  subdivided  into  inspection,  palpation, 
and  auscultation.  In  the  use  of  this  method  of  examination  it  is  best  for  the 
beginner  to  ignore  the  possibility  of  O.  L.  P.  and  O.  D.  A.,  on  account  of 
their  great  infrequency  and  of  the  excessive  complications  that  an  effort  at 
their  recognition  would  involve. 

The  value  which  the  individual  obstetrician  places  upon  an  abdominal 
examination  is  generally  proportionate  to  the  experience  he  has  enjoyed.  The 
beginner  should  be  urged  to  avail  himself  of  every  opportunity  for  practising 
this  method,  for,  while  he  will  find  in  his  early  practice  many  cases  in  which 
the  obesity  of  the  patient  or  the  rigidity  of  the  abdominal  muscles  and  uterus 
renders  abdominal  palpation  of  no  value,  a  large  number  in  which  the  exam- 
ination is  inconclusive,  and  only  a  few  in  which  he  can  attain  a  clear  diagnosis 
by  this  means,  yet  as  his  experience  enlarges  the  first  class  will  steadily  decrease 
in  number  and  the  latter  two  will  increase  proportionately,  if  he  is  faithful  in 
practising  palpation  upon  every  case  that  comes  under  his  charge;  and  the 
value  which  attaches  to  facility  in  making  a  diagnosis  by  this  means  in  many 
difficult  operative  cases  can  be  appreciated  only  by  those  who  possess  it.  It  is 
certainly  a  fact  that  to  the  experienced  hand  abdominal  palpation  yields  results 
fully  as  valuable  as  those  which  can  be  obtained  by  digital  examination  per 
vaginam,  and  that  there  are  but  few  cases  in  which  repeated  examinations 
during  the  progress  of  labor  will  fail  to  establish  a  diagnosis  by  palpation  and 
auscultation  alone. 

Abdominal  Inspection. — Inspection  is  mainly  valuable  as  affording  a  hint 
of  the  existence  of  transverse  presentations  and  of  multiple  pregnancy. 

Abdominal  Palpation. — Palpation  is  the  most  important  part  of  the 
abdominal  examination;  it  should  be  performed  onlv  in  the  intervals  between 

*  Although  the  methods  which  must  be  used  in  making  the  diagnosis  of  presentation  and 
position  are  indicated  in  another  part  of  this  work,  such  a  diagnosis  is  so  essential  to  the 
mechanical  management  of  labor  that  it  seems  wise  to  repeat  in  brief  the  technique  of  the 
several  methods  of  examination  in  this  section. 


458  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

the  pains,  all  pressure  of  the  hand  being  intermitted  with  the  appearance  of 
each  contraction.  The  physician  should  stand  by  the  patient's  side  facing 
toward  her  head,  and  should  apply  the  pain:  of  each  hand  flat  against  the  cor- 
responding side  of  the  uterus.  Throughout  the  examination  it  is  all-important 
that  the  motions  of  the  hand  should  be  slow  and  gentle,  any  quick  or  jerky 
impulse  being  almost  certain  to  result  in  rigidity  of  the  abdominal  walls  and  the 
uterus,  thus  frustrating  the  purpose  of  the  examination.  Every  effort  should 
be  made  to  divert  the  attention  of  the  patient,  to  soothe  her  fears,  and  to  assure 
her  that  the  examination  will  uot  be  painful.  It  not  infrequently  happens  that 
the  first  attempt  will  be  a  total  failure,  while  the  second  will  yield  satisfactory 
results  owing  to  the  changed  mental  condition  of  the  patient. 

Diagnosis  of  Presentation  by  Palpation. — The  finger-tips  of  each  hand 
should  be  pressed  with  a  gradual  and  gentle  motion  downward  behind  the 
symphysis  pubis  in  search  of  the  fetal  head  (Fig.  231),  which  in  cephalic  pres- 


Fig.  231.— Diagnosis  of  presentation  by  palpation. 

entations  is  almost  always  to  be  felt  in  this  situation  as  a  marked  transverse 
check  to  the  examining  hand.  In  this  examination  care  should  be  taken  to 
note  on  which  side  the  head  is  most  plainly  perceived,  since  with  a  well-flexed 
head  the  frontal  extremity  is  much  the  more  easily  reached,  with  the  partially 
extended  head  but  little  difference  is  to  be  noticed,  and  in  face  presentations 
the  occiput  is  much  the  more  distinct. 

The  fundus  should  then  be  palpated  carefully  as  a  further  means  of 
excluding  the  possibility  of  a  breech  presentation.  The  head  may  be  dis- 
tinguished from  the  breech  at  the  fundus  by  its  greater  size  and  mobility, 
by  its  rounded  contour  as  opposed  to  the  tapering  form  of  the  smaller 
breech,  and  by  an  easily  distinguished  sulcus  which  corresponds  with  the  neck 
of  the  child  ;  but  the  best  evidence  of  the  presence  of  the  breech  at  the  fundus 


THE   MECHANISM   OF  LABOR.  459 

is  always  the  recognition  of  a  head  presentation  by  deep  palpation  behind  the 
symphysis. 

Differential  Diagnosis  of  Presentations  by  Palpation. — Cephalic  Presenta- 
tions.— The  most  distinctive  sign  of  head  presentations  is  to  be  found  in  the 
recognition  of  the  head  by  deep  palpation  behind  the  symphysis.  The  diag- 
nosis should  then  be  checked  by  ascertaining  the  absence  of  the  signs  charac- 
teristic of  the  head  at  the  fundus. 

Pelvic  Presentations. — In  breech  presentations  the  obstetrician's  attention 
is  generally  first  arrested  by  the  absence  of  the  transverse  check  to  the  fingers, 
due  to  the  presence  of  the  head,  on  deep  palpation  behind  the  symphysis. 
He  should  then  be  able  to  recognize  the  presence  of  the  head  at  the  fundus  by 
the  signs  just  enumerated. 

Transverse  Presentations. — In  transverse  presentations  the  long  axis  of  the 
child  is  felt  to  be  transverse.  The  differential  diagnosis  between  the  head 
and  the  breech  is  always  of  importance,  and  is  to  be  made  by  the  signs  enu- 
merated above  as  characteristic  of  the  head. 

Diagnosis  of  Position  by  Palpation. — The  hands  should  be  placed  along 
the  sides  of  the  uterus  and  should  make  gentle  but  deep  pressure  toward  each 
other  (Fig.  232) — that  is,  with  the  uterus  and  child  directly  between  their 


Fig.  232.— Diagnosis  of  position  by  palpation. 

palms — in  the  effort  to  estimate  the  relative  resistance  afforded  by  the  right 
and  left  sides  of  the  uterus,  the  flat,  firm  back  of  the  child  usually  presenting 
a  resistance  to  pressure  that  is  markedly  greater  than  that  of  the  yielding 
abdomen  and  the  movable  limbs. 

The  differing  resistances  having  been  estimated,  the  fingers  should  be 
applied  to  the  sides  of  the  uterus,  not  with  the  tips  deeply  indented  into  the 
abdomen,   but  with  their  whole  palmar  surface  pressed  firmly  against  the 


4(30  AMERICAN    TEXT-BOOK    OF   OBSTETRICS. 

uterus ;  the  hands  should  then  be  moved  gently  up  and  down  along  the 
uterine  wall  in  an  endeavor  to  recognize  the  irregularities  due  to  the  presence 
of  the  fetal  limbs.  During  this  search  it  is  necessary  to  guard  against  the 
error  of  mistaking  either  of  the  round  ligaments  for  the  fetal  members.  These 
ligaments,  which  at  term  are  of  nearly  the  size  of  the  adult  finger,  extend 
obliquely  from  the  cornua  of  the  uterus  downward,  outward,  and  forward  to 
the  pelvic  brim.  They  may  be  recognized  by  their  situation  and  by  the  pain 
of  which  the  patient  invariably  complains  when  they  are  rolled  about  under 
the  fingers.  The  existence  of  small  subperitoneal  fibroids  is  another  possible 
source  of  error.  With  thin  and  flaccid  abdominal  walls  it  is  sometimes  possi- 
ble by  this  method  to  recognize  the  fetal  limbs  with  the  utmost  distinctness, 
but  in  the  majority  of  cases  an  irregularity  in  the  contour  of  the  fetus  is  all 
that  can  be  hoped  for. 

By  palpation,  then,  we  can  hope  to  distinguish  not  only  the  presentation,  but 
also  the  position,  since  the  latter  must  correspond  with  the  quarter  of  the  pelvis 
in  which  the  fetal  back  is  found.  Owing  to  the  infrequency  of  O.  D.  A.  and 
O.  L.  P.  positions,  it  is  generally  safe  to  call  all  cases  in  which  the  back  of  the 
child  is  found  toward  the  left,  O.  L.  A.,  and  those  in  which  it  is  found  toward 
the  right  of  the  mother,  O.  IX  P. 

Abdominal  Auscultation. — Auscultation  of  the  fetal  heart  gives  confirm- 
atory evidence  about  the  presentation  and  position,  informs  us  of  the  condi- 
tion of  the  child,  and  is  the  most  important  sign  in  the  recognition  of  multiple 
pi-egnancy. 

In  vertex  presentations  the  heart  is  most  plainly  heard  over  the  back  of 
the  child  and  below  the  mother's  umbilicus ;  *  in  breech  presentations  the 
heart  is  heard  over  the  back,  but  its  greatest  intensity  is  generally  above  the 
mother's  umbilicus ;  while  in  presentations  of  the  face  it  is  most  readily  heard 
over  that  portion  of  the  uterus  which  corresponds  with  the  chest  of  the  child, 
but  is  again  below  the  umbilicus.  In  transverse  presentations  the  heart  is 
usually  plainly  audible  when  the  back  is  anterior,  but  is  often  found  with 
difficulty  in  the  posterior  varieties,  and  is  of  comparatively  little  value  in  the 
diagnosis  of  position. 

In  interpreting  the  evidence  of  position  furnished  by  the  situation  of  the  fetal 
heart  it  must  not  be  forgotten  that,  owing  to  the  fact  that  sound  is  better  con- 
ducted by  solids  than  by  liquids,  the  exact  situation  of  the  fetal  heart-sounds 
corresponds  with  that  portion  of  the  back  or  chest  which  happens  at  the  moment 
to  be  in  contact  with  the  uterine  wall ;  the  situation  of  the  fetal  heart-sound, 
therefore,  may  vary  temporarily  with  the  position  of  the  mother,  as  one  or 
the  other  shoulder  rests  against  her  soft  parts,  or  it  may  temporarily  be  absent 
(especially  when  the  patient  lies  upon  her  back),  owing  to  the  intervention  of 
the  liquor  amnii  between  the  fetal  chest  and  the  physician's  ear. 

*  Owing  to  the  oblique  position  which  the  shoulders  normally  occupy,  the  dividing-line 
between  the  right  and  the  left  position  of  the  heart-sounds  in  this  and  in  all  longitudinal  pres- 
entations should  be  that  drawn  between  the  umbilicus  and  the  right  anterior  superior  spine 
of  the  ilium  rather  than  the  median  line  of  the  body. 


THE   MECHANISM   OF  LABOR.  461 

In  addition  to  the  value  of  auscultation  in  the  diagnosis  of  position,  its 
importance  in  the  recognition  of  the  condition  of  the  fetus  can  hardly  be  over- 
estimated, any  fatigue  of  importance  being  quickly  shown  by  alteration  of  the 
rate  and  regularity  of  the  heart-sounds.  In  addition  to  the  fetal  heart-sounds, 
the  so-called  "uterine"  or  "placental  souffle"  is  generally  heard  as  a  soft 
blowing  sound  synchronous  with  the  mother's  pulse  ;  this  sound  is  of  no 
practical  value. 

Summary  of  Diagnostic  Signs  furnished  by  the  Abdominal  Exami- 
nation.— At  the  conclusion  of  the  abdominal  examination  its  results  should 
be  summed  up  and  a  diagnosis  be  made  by  some  such  mental  process  as  the 
following : 

The  first  process  of  palpation,  described  on  page  459,  enables  one  to  deter- 
mine whether  the  presentation  is  cephalic,  pelvic,  or  transverse,  and  this  result 
is  checked  by  the  position  of  the  fetal  heart  as  obtained  by  auscultation  ;  that 
is,  in  cephalic  presentations  the  heart  is  found  below  the  umbilicus,  in  breech 
presentations  above  it,  and  in  transverse  presentations  a  little  toward  that  side 
of  the  abdomen  to  which  the  head  is  directed. 

The  position  is  determined  by  the  situation  of  the  fetal  back,  as  established 
by  the  second  method  of  palpation,  described  on  page  459,  and  by  the  position 
of  the  fetal  heart,  which  position  should  correspond  with  that  of  the  fetal  back.* 

If  the  presentation  is  either  breech  or  transverse,  no  further  determination 
is  necessary,  or  indeed  possible,  by  the  abdominal  examination;  but  if  the  pres- 
entation is  cephalic,  it  is  both  necessary  and  possible  to  determine  whether  it 
is  a  presentation  of  the  vertex,  the  brow,  or  the  face.  In  vertex  presentations 
the  end  of  the  head  that  corresponds  with  the  fetal  abdomen — that  is,  the  face — 
is  found  at  a  higher  level  than  the  opposite  or  occipital  end,  and  the  fetal  heart 
is  heard  over  the  back.  In  face  presentations  the  end  of  the  child's  head  that 
corresponds  with  the  abdomen — that  is,  the  face — is  palpated  less  readily  than 
the  dorsal  (occipital)  end  of  the  head,  and  the  heart  is  heard  over  the  front  of 
the  child.! 

In  brow  presentations  both  ends  of  the  head  are  easily  reached  by  palpation. 
The  heart  is  usually  heard  over  the  back. 

Vaginal  Examination. — Technique  of  the  Examination. — In  obstetric  work 
it  is  usually  best  to  avail  one's  self  of  the  extra  length  of  the  middle  finger 
by  employing  two  fingers  for  all  examinations,  except  in  those  cases  in  which 
the  extremely  narrow  vulva  of  a  primipara  makes  the  introduction  of  the 
second  finger  painful  to  the  patient.     Most  American  obstetricians  prefer  to 

*  Except  in  face  presentations  (see  p.  509. 

f  It  will  be  perceived  that  the  distinction  between  vertex  and  face  presentations  by  abdom- 
inal examination  is  likely  to  be  difficult,  since  in  a  left  anterior  position  of  either  presentation 
the  most  accessible  end  of  the  head  will  be  found  in  the  right  posterior  quarter,  while  in  both 
presentations  the  heart  is  left  anterior ;  the  only  distinction  is  to  be  found  in  the  position  of 
the  fetal  limbs  as  compared  with  the  heart,  and  in  the  perception  of  the  greater  size  and  more 
rounded  contour  of  the  occiput  as  opposed  to  the  face;  but  the  great  infrequency  of  face  pres- 
entations and  the  ease  with  which  they  are  distinguished  on  vaginal  examination  make  this 
source  of  error  a  matter  of  small  importance. 


462  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

examine  the  patient  when  in  the  left  lateral  decubitus,  but  it  is  well  to  accustom 
one's  self  to  examining  in  all  positions,  not  only  in  the  interest  of  the  patient's 
comfort  and  convenience,  but  also  because  it  is  often  possible  by  changing  the 
decubitus  to  reach  a  portion  of  the  child  that  has  before  been  unattainable. 

The  vulva  being  aseptic,  the  hand,  having  been  thoroughly  disinfected  and 
anointed  with  an  aseptic  lubricant,  should  be  introduced  under  the  bed-clothes, 
which  should  be  so  held  up  by  the  other  hand  as  to  protect  them  from  contact 
with  the  examining  fingers ;  these  should  be  placed  against  the  genital  cleft, 
and  be  swept  gently  forward  until  they  find  the  entrance  of  the  vulva  and 
come  in  contact  with  the  fourchette,  friction  against  the  vestibule  and  clitoris 
being  carefully  avoided  in  the  process. 

As  the  examining  finger  enters  the  vagina  it  should  note  successively  the 
size  of  the  vulvar  orifice,  the  position  of  the  coccyx,  the  shape  of  the  sacrum,* 
and  the  condition  of  the  rectum — whether  full  or  empty.  These  points  having 
been  ascertained,  the  finger  should  be  passed  upward  into  the  posterior  fornix, 
and  be  swept  forward  over  the  soft  and  yielding  vault  of  the  vagina  in  the 
effort  to  find  the  external  os,  which  is  usually  situated  in  the  median  line  and 
near  the  centre  of  the  pelvis.  In  case  of  failure  to  find  the  os  readily,  the  field  of 
the  pelvis  should  be  quartered  systematically  by  the  examining  finger,  much  after 
the  fashion  employed  by  a  pointer  dog  in  searching  a  field  for  game.  If  the 
cervix  be  not  yet  taken  up,  it  is  recognized  as  a  rounded  prominence,  on  the 
summit  of  which  is  found  the  orifice  of  the  os  if  the  patient  be  a  primipara ; 
in  multiparas  the  lacerated  and  ragged  condition  of  the  cervix  frequently  makes 
the  external  os  indistinguishable  from  an  early  stage  of  labor,  but  the  finger 
in  such  cases  may  usually  be  passed  into  the  cervical  canal,  and  will  then 
recognize  the  presence  of  the  internal  os.  If  the  cervix  has  been  wholly 
taken  up,  the  os  is  best  recognized  by  passing  the  finger  through  it  and  into 
the  space  between  the  cervix,  and  the  presenting  part.f 

The  physician's  ability  to  reach  the  upper  portions  of  the  pelvis  is  more 
dependent  upon  the  position  in  which  his  hand  is  held  than  upon  the  length 
of  his  fingers.  When  he  desires  to  reach  the  upper  and  posterior  parts  of  the 
pelvis,  his  hand  should  be  held  in  the  position  indicated  in  Figure  233,  the 
perineum  being  strongly  retracted  by  the  pressure  of  the  web  between  the 
second  and  third  fingers.  When  the  object  sought  for  lies  nearer  the  anterior 
wall  of  the  pelvis,  the  position  of  the  hand  should  be  altered  by  rotation  of 
the  forearm  into  the  position  represented  in  Figure  234.  The  upper  border 
of  the  second  finger  is  now  pressed  firmly  against  the  edge  of  the  pubic  arch, 
and  the  pulp  of  the  finger  is  directed  anteriorly. 

*  The  writer  strongly  recommends  the  practice  of  roughly  measuring  the  conjugate  diameter 
by  reaching  upward  for  the  promontory  of  the  sacrum,  as  a  routine  measure,  at  the  conclusion 
of  the  first  examination  in  each  case,  and  he  believes  that  many  operative  difficulties  may  be 
avoided  by  this  simple  procedure. 

I  Unless  this  precaution  of  hooking  the  finger  about  the  edge  of  the  os  be  observed,  the 
beginner  is  liable  to  mistake  a  fold  of  the  vaginal  wall,  or  in  breech  presentations  the  anus,  for 
the  os  uteri,  both  of  which  mistakes  have  been  made  by  medical  students  in  the  presence  of 
the  writer. 


THE   MECHANISM    OF  LABOR. 


463 


The  os  having  been  reached,  the  finger  should  note  its  size,  the  thickness 
of  its  edge,  and  its  consistency,  whether  hard  or  soft,  and  by  very  gentle  stretch- 
ing should  endeavor  to  ascertain  its  degree  of  dilatabilitv  ;  in  this  last  maneu- 
vre  it  is  necessary  to  employ  the  greatest  gentleness  in  order  to  avoid  the  inex- 


Fig.  233.— Positon  of  the  hand  in  digital  examinat 


along  the  posterior  wall  of  the  pelvis. 


disable  accident  of  a  manual  laceration  of  the  os  during  examination.  The 
characteristically  different  sensations  yielded  to  the  finger  by  the  smooth  and 
velvety  cervix,  the  rough  but  slippery  membranes,  and  the  hairy  scalp  is  a 
matter  with  which  it  is  important  to  become  familiar,  for  it  is  easy  to  recognize 


t<::- 

■ 

j 

IR^^s 

"V  ^ 

Fig.  234.— Position  of  the  band  in  digital  < 


if  the  fetus  along  the  anterior  wall  of  the  pelvis. 


these  differences  if  the  physician  has  trained  himself  to  observe  them  in  even 
a  comparatively  small  number  of  cases,  and  the  possession  of  this  facultv  may 
at  some  time  preserve  him  from  the  dangerous  or  even  fatal  error  of  making 
an  application  of  the  forceps  to  the  intact  membranes  or  over  an  undilated 
cervix. 

If  the  cervix  is  thin,  it  may  be  possible  to  recognize  the  presenting  part 


464  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

through  its  substance;  but  in  ordinary  cases  it  is  necessary  to  introduce  the 
finger  through  the  os  in  order  to  distinguish  between  the  different  parts  of  the 
child.  The  finger  should  be  passed  up  until  it  comes  in  contact  with  the  pre- 
senting part,  and  it  should  then  seek  systematically  for  marks  by  which  the 
character  of  this  part  can  be  determined.  The  presence  of  the  head  is  to  be 
determined  by  the  perception  of  one  or  more  sutures ;  that  of  the  face,  by  the 
presence  of  the  mouth  and  nose  ;*  that  of  the  breech,  by  the  recognition  of 
the  spinous  processes  of  the  sacrum,  the  genitals,  and  the  anus.  The  tuberos- 
ities of  the  ischia  and  the  pubic  arch  are  also  easily  recognizable.  The  shoulder 
presents  no  very  distinctive  marks,  and  the  diagnosis  of  a  transverse  presenta- 
tion is  not  easily  made  by  vaginal  examination  during  the  early  stages  of 
labor  unless  a  hand  and  an  arm  are  prolapsed,  but  it  should  always  have  been 
recognized  by  abdominal  palpation  before  the  vaginal  examination  is  made. 
The  various  distinctive  marks  of  each  of  the  presentations  must  be  sought  for, 
and  the  diagnosis  is  to  be  made  in  accordance  with  those  found  to  be  present. 

The  diagnosis  of  presentation  by  vaginal  examination,  though  ordinarily 
easy,  is  sometimes  difficult  when  the  presenting  part  is  still  high  in  the  pelvis. 
It  would  be  supposed,  a  priori,  that  the  distinction  between  the  hard  head 
and  the  yielding  breech  could  be  made  in- all  cases  with  the  greatest  ease,  but 
a  considerable  experience  in  the  superintendence  of  students  has  convinced 
the  writer  that  this  point  of  consistency  is  a  most  unsafe  and  unsatisfactory 
guide,  and  some  personal  experiences  have  led  him  to  adopt  the  rule  of  never 
permitting  himself  to  diagnose  a  head  unless  it  is  possible  to  recognize  at  least 
one  suture,  nor  to  commit  himself  to  the  diagnosis  of  a  breech  without  inserting 
the  examining  finger  into  the  anus  and  recognizing  the  presence  of  the  coccyx. 

Summary  of  Signs  of  each  Presentation. —  Vertex  Presentations. — In 
vertex  presentations  the  finger  should  first  recognize  the  convergence  of 
the  lambdoidal  and  sagittal  sutures  forming  the  small  fontanelle.  The 
finger  should  then  pass  along  the  sagittal  suture  until  it  reaches  the  large 
fontanelle  and  recognizes  the  four  sutures  which  enter  it.  It  should  next 
search  for  the  ears,  the  mastoid  processes,  and  the  lateral  fontanelles, 
all  of  which  may  usually  be  found  by  following  the  lambdoidal  sutures  to 
their  terminations.  The  ear  is  always  recognizable,  the  mastoid  and  the  lateral 
fontanelles  are  less  constantly  conspicuous,  and  all  these  marks  are  usually  less 
easilv  reached  upon  the  posterior  than  upon  the  anterior  side.  The  ear,  when 
reached,  always  points  toward  the  occipital  end  of  the  head,  unless,  as  sometimes 
happens,  it  is  folded  forward  against  the  scalp — a  fact  which  is  easily  recognized 
if  the  finger  is  passed  backward  and  forward  a  few  times  across  the  ear.  With 
a  well-flexed  head  the  posterior  fontanelle  is  lower  in  the  pelvis  than  is  the 
bregma,  and  the  upper  and  posterior  part  of  the  ear  is  generally  the  more 
easily  accessible.  When  the  head  is  somewhat  extended  the  fontanelles  are 
upon  about  the  same  level  in  the  pelvis,  and  the  anterior  edge  of  the  ear  is 
most  easily  reached.     With  extreme  extension  of  a  vertex  presentation  the 

*  Care  must  be  taken  not  to  mistake  the  supraorbital  ridges  of  a  face  presentation  for  the 
suboccipital  ridges  of  a  well-flexed  vertex  presentation. 


THE   MECHANISM    OF  LABOR.  465 

eyebrows  are  not  infrequently  accessible  (see  Brow  Presentations).  The  diag- 
nosis of  position  in  vertex  presentations  is  made  by  ascertaining  the  position 
of  the  occiput ;  this  is  obtained,  first,  by  comparing  the  positions  of  the  small 
and  large  fontanelles  in  the  pelvis,  and,  second,  by  observing  the  direction  in 
which  the  flaps  of  the  ears  point. 

Broiv  Presentations. — When  the  extension  is  so  extreme  that  the  small 
fontanelle  is  reached  with  difficulty  and  the  supraorbital  ridges  and  the  bridge 
of  the  nose  are  well  below  the  brim  of  the  pelvis,  the  presentation  is  that  of 
a  brow.  By  very  high  examination  the  mouth  can  occasionally  be  touched  in 
brow  presentations.  The  position »is  named  after  the  position  of  the  small 
fontanelle,  but  care  should  be  taken  to  check  the  diagnosis  by  an  independent 
observation  of  the  position  of  the  root  of  the  nose,  which  should,  of  course, 
be  in  the  opposite  quarter  of  the  pelvis. 

Face  Presentations. — When  the  supraorbital  ridges  are  found  upon  one  side 
of  the  pelvis  and  the  point  of  the  chin  upon  the  other,  the  presentation  is  a 
face.  Before  the  diagnosis  is  considered  assured  the  fingers  should  recognize, 
in  addition  to  the  chin  and  the  supraorbital  ridges,  the  mouth,  the  nostrils,  the 
eyes,  and  the  root  of  the  nose  in  their  proper  positions;  and  it  is  even  well  to 
adopt  the  precaution  of  always  inserting  the  finger  into  the  mouth  and  ascer- 
taining the  presence  of  the  maxillary  processes  and  the  tongue,  which  can  be 
mistaken  for  nothing  else.  The  position  is  indicated  by  the  position  of  the 
chin,  and  should  be  checked  by  an  observation  of  the  position  of  the  frontal 
suture. 

Breech  Presentations. — In  breech  presentations  we  must  distinguish,  during 
the  vaginal  examination,  between  presentations  of  the  whole  breech  and  foot- 
ling presentations.  In  presentations  of  the  whole  breech  the  finger  should 
recognize  the  spinous  processes  of  the  sacrum,  the  anus,  and  the  genital  cleft. 
In  boys  the  scrotum  often  becomes  enormously  distended,  and  this  may  lead 
to  confusion  if  the  possibility  of  the  fact  is  not  borne  in  mind.  When  a 
breech  presentation  is  found,  the  finger  should  always  be  inserted  into  the 
anus,  and  be  made  to  recognize  the  tip  of  the  coccyx,  the  tuberosities  of  the 
ischium,  and  the  pubic  arch.  The  position  is  named,  as  has  been  said,  after 
the  position  of  the  sacrum,  and  it  is  most  easily  determined  by  finding  the 
position  of  the  tip  of  the  coccyx  of  the  fetus  by  rectal  examination.  In  foot- 
ling presentations  one  or  both  ankles  or  feet  protrude  through  the  os. 

Presentation  of  a  Hand  or  a  Foot. — If  the  membranes  be  ruptured,  a  pre- 
senting hand  or  a  foot  may  easily  be  drawn  outside  the  vulva  and  be  recognized 
by  the  eye ;  if  this  be  impossible,  it  may  easily  be  differentiated  by  the  touch 
through  the  membranes  by  observation  of  the  following  points :  The  foot  is 
to  be  distinguished  from  the  hand  by  the  presence  of  the  malleoli  and  of  the 
prominence  of  the  heel,  and  by  the  facts  that  the  great  toe  is  of  equal  or 
greater  length  than  the  others  and  is  placed  in  the  same  plane  with  them ; 
while  the  hand  is  recognized  by  the  absence  of  the  heel,  by  the  fact  that  it 
can  be  placed  in  direct  continuation  of  the  line  of  the  limb  to  which  it  is 
attached,  and  that  the  thumb  is  shorter  than  the  fingers  and  can  be  opposed 


466  A3IEBICAJX    TEXT-BOOK    OF    OBSTETRICS. 

to  them.  The  importance  of  avoiding  rupture  of  the  membranes  in  such 
presentations  is,  however,  so  great  that  it  is  usually  best  to  trust  to  the  results 
of  external  palpation. 

Presentations  of  the  Knee  and  the  Elbow. — The  knee  may  sometimes  be  dis- 
tinguished from  the  elbow  by  the  presence  of  the  patella ;  but,  since  the  latter 
is  small  and  not  always  easy  of  recognition,  it  is  best  to  distinguish  between 
these  two  joints  by  following  the  course  of  the  limb  to  its  termination  in  a 
hand  or  a  foot  as  the  case  may  be. 

Transverse  Presentations. — The  shoulder  is  liable  to  be  mistaken  only  for 
the  breech,  from  which  it  may  be  distinguished  by  the  presence  of  but  one 
limb  in  place  of  the  two  which  are  attached  to  the  pelvis,  and  by  recognition 
of  the  smooth  ridge  of  the  scapula  as  opposed  to  the  rough  spines  of  the 
sacrum  ;  recognition  of  the  clavicle  and  the  ribs  will  also  assist  the  diagnosis ; 
but  the  recognition  of  a  shoulder  by  vaginal  examination  is  extremely  diffi- 
cult, and  the  existence  of  the  presentation  is  practically  ascertained,  in  the 
majority  of  cases,  by  external  palpation,  without  assistance  from  vaginal 
examination. 

In  presentations  of  the  hand  it  is  sometimes  possible  to  make  a  diagnosis 
of  position  by  observation  of  the  hand  alone  ;  to  this  end  it  is  first  necessary  to 
determine  which  hand  of  the  fetus  presents,  this  being  best  ascertained  by 
attempting  to  shake  bands  with  the  presenting  part,  the  right  hand  of  the  fetus 
coming  into  position  to  shake  hands  with  the  right  hand  of  the  physician,  and 
the  left  with  the  left.  If  the  presenting  hand  be  turned  by  rotation  of  the 
forearm  into  forced  supination,  the  thumb  points  to  the  side  on  which  lies  the 
fetal  head,  and  the  back  of  the  hand  corresponds  with  the  back  of  the  fetus  ;  but 
in  actual  practice  the  attitude  of  the  child  so  seldom  corresponds  exactly  to  any 
one  of  the  four  classical  positions  that  this  evidence  is  of  comparatively  slight 
value,  and  is  only  to  be  used  as  confirmatory  of  the  results  of  palpation. 

Frequency. — The  vertex  presents  in  about  97  per  cent,  of  all  labors,  the 
breech  presents  in  about  2  per  cent.,  and  the  remaining  1  per  cent,  is  made 
up  of  brow,  face,  and  transverse  presentations,  the  latter  two  being  the  move 
frequent. 

Prognosis. —  Vertex  Presentations. — In  vertex  presentations  the  prognosis 
for  both  mother  and  child  is  better  than  in  any  other  variety  of  labor.  It 
varies,  however,  to  some  slight  degree  with  the  position,  being  better  in  ante- 
rior than  in  posterior  positions,  on  account  of  the  somewhat  longer  and  more 
difficult  labors  which  are  to  be  expected,  as  will  be  seen,  in  the  latter. 

Face  Presentations. — In  face  presentations  the  prognosis,  though  not  neces- 
sarily bad,  is  always  worse  for  both  mother  and  child  than  in  vertex  cases ; 
for.  although  a  minority  of  face  labors  are  terminated  with  safety  and  rapid- 
ity by  the  efforts  of  nature,  yet  in  those  cases  in  which  an  arrest  occurs, 
and  in  which  art  must  step  in,  the  delivery  is  often  difficult.  The  prog- 
nosis for  the  mother  is  that  of  the  operation  indicated,  but  in  the  opera- 
tive delivery  of  face  cases  the  dangers  to  the  fetus  are  always  peculiarly 
great. 


THE  MECHANISM   OF  LABOR.  467 

Brow  Presentations. — In  brow  presentations  the  prognosis  for  both  patients 
is  that  of  the  operation  by  which  the  case  is  delivered.  It  is  therefore  neces- 
sarily worse  than  that  of  vertex  presentations. 

Breech  Presentations. — In  breech  presentations  the  prognosis  for  the  mother 
is  only  altered  from  the  normal  by  the  fact  that  the  rapid  extraction  of  the 
after-coming  head  and  arms  that  is  very  frequently  necessary  is  attended 
by  a  considerably  increased  liability  to  perineal  and  cervical  lacerations. 
The  prognosis  for  the  child  is  always  bad,  especially  among  primiparse  or 
with  women  who  for  any  other  reason  have  rigid  soft  jjarts. 

Transverse  Presentations. — Transverse  presentations  must  always  be  termi- 
nated by  art,  and  the  prognosis  varies  with  the  period  of  labor  at  which  inter- 
ference is  undertaken.  In  uncomplicated  transverse  presentations  an  early 
version  is  usually  easy,  and  the  prognosis  for  both  patients  is  therefore  good. 
In  neglected  cases  the  operation  is  always  difficult,  and  the  prognosis  for  both 
patients  is  bad. 

1.  Vertex  Presentations. 

Frequency  of  Cephalic  Presentations. — At  the  end  of  pregnancy  the 
cephalic  end  of  the  child  presents  in  about  97  per  cent,  of  all  cases.  In 
97,871  births  in  private  practice  Spiegelberg  found  head  presentations  in 
over  97  per  cent.  In  23,000  cases  confined  in  Guy's  Hospital  Lying-in 
Charity  the  percentage  of  head  presentations  was  96.9.  Premature  delivery 
and  stillbirth  of  the  fetus  decrease  greatly  the  proportion  of  head  pres- 
entations. Thus,  Collins  found  that  head  presentations  occurred  in  97  per 
cent,  of  living  children  among  about  16,000  deliveries  at  term,  and  in  only 
about  80  per  cent,  among  500  births  of  putrid  fetuses.  Churchill  found  that 
at  seven  months  only  83  per  cent,  of  living  and  53  per  cent,  of  dead  children 
are  born  by  cephalic  presentation.  DuBois  found  83  to  be  the  percentage  for 
living  children  and  45  for  dead  children  at  the  same  period. 

It  is  found  that  during  the  latter  months  of  pregnancy  changes  in  the 
presenting  pole  of  the  fetus  occur  once  or  more  in  from  35  to  40  per  cent,  of 
all  cases.  The  change  from  a  pelvic  or  a  transverse  presentation  to  a  cephalic, 
however,  is  very  much  commoner  than  the  loss  of  a  cephalic  presentation. 
The  latter  would  therefore  seem  to  be  the  position  of  more  stable  equilibrium, 
and  it  will  be  found  that  these  observations — namely,  the  decreased  percentage 
of  head  presentations  among  premature  and  stillborn  children,  and  the  greater 
stability  of  head  presentation  as  compared  with  any  other — have  an  important 
bearing  upon  the  etiology  of  the  presentations. 

Relative  Frequency  of  the  Four  Positions. — In  about  75  per  cent,  of  all 
cephalic  presentations  the  occiput  is  found  upon  the  left  side  of  the  mother, 
and  in  more  than  73  per  cent,  of  this  75  per  cent,  the  position  is  anterior — 
that  is,  O.  L.  A.  In  the  remaining  25  per  cent,  the  occiput  is  of  course 
directed  to  the  right  side  of  the  mother,  but  the  determination  of  the  relative 
frequency  of  right  anterior  and  right  posterior  positions  is  not  so  easily  de- 
termined,  there  being  gi'eat  differences  of   opinion   upon  this  point  among 


468  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

different  observers,  the  key  to  this  difference  of  opinion  being  probably 
found  in  their  adoption  of  different  periods  of  labor  for  the  determination  of 
the  position. 

In  a  large  proportion  of  those  cases  in  which  the  occiput  is  to  the  right 
and  somewhat  anterior  at  the  very  beginning  of  labor — that  is,  before  the 
head  is  even  pressed  into  the  superior  strait — the  position  becomes  right  pos- 
terior as  soon  as  engagement  occurs.  It  is  probable  that  some  observers  have 
classified  such  cases  as  O.  D.  A.,  and  others  as  O.  D.  P.  Again,  the  enormous 
majority  of  right  posterior  positions  become  right  anterior  by  rotation  during 
the  second  stage  of  labor.  An  observer  who  made  his  diagnosis  only  during 
the  latter  part  of  the  second  stage  would  class  all  such  cases  as  anterior  posi- 
tions. It  is  certainly  a  fact  that  the  vast  majority  of  right  positions  are 
right  posterior  positions  at  the  time  when  the  greatest  diameter  of  the  head 
occupies  the  superior  strait ;  and  if  this  period  of  labor  be  selected  as  the  time 
when  the  position  should  be  determined,  it  is  safe  to  say  that  nearly  75  per 
cent,  of  all  cases  are  primarily  O.  L.  A.,  and  almost  20  per  cent,  are  primarily 
O.  D.  P.  Of  the  small  remainder,  almost  4  per  cent,  are  primarily  O.  D.  A., 
and  but  a  little  over  1  per  cent,  are  O.  L.  P. 

Etiology  of  Presentations. — Three  conditions  have  been  urged  as  chiefly 
contributing  to  the  frequency  of  cephalic  presentations,  and  it  seems  probable 
that  the  true  cause  must  be  found  in  a  combination  of  all  three  conditions, 
which  probably  vary  in  their  importance  in  individual  cases.  These  three 
causes  are — first,  the  effect  of  gravity  ;  second,  the  easier  adaptation  of  the 
fetus  to  the  uterine  cavity  in  head  presentations;  and  third,  the  effect  of  active 
movements  on  the  part  of  the  fetus. 

In  estimating  the  relative  importance  of  these  factors  in  the  etiology  of 
head  presentations,  it  is  evident  that  to  attain  the  truth  it  is  necessary  to  reach 
a  conclusion  which  will  explain  the  results  of  clinical  observation  recorded 
above,  and  which  will  make  evident  not  only  the  reasons  for  the  great  prepon- 
derance of  cephalic  presentations  of  the  fetus,  but  also  for  its  variability  in 
accordance  with  the  period  of  delivery  and  the  condition  of  the  fetus. 

The  Influence  of  Gravity. — It  has  been  found  by  experiment  that  if  a  re- 
cently-dead fetus  at  term  be  immersed  in  a  saline  fluid  of  the  specific  gravity  of 
the  liquor  amnii,  it  tends,  under  the  influence  of  gravity,  to  assume  an  oblique 
position,  with  the  head  lower  than  the  breech  and  the  right  side  lower  than 
the  left.  This  fact  is  explained  by  Matthews  Duncan,  who  has  shown  that  the 
specific  gravity  of  the  fetal  head  is  greater  than  that  of  the  decapitated  trunk, 
and  that  the  greater  specific  gravity  of  the  right  side  is  clue  to  the  enormous 
relative  size  of  the  liver  in  the  new-born  child.  It  is  evident,  then,  other 
conditions  being  equal,  that  we  may  expect,  in  a  preponderance  of  cases,  to 
find  the  head  and  right  shoulder  of  the  fetus  in  that  portion  of  the  uterus 
which  is  horizontally  lowest  in  the  ordinary  positions  of  the  mother. 

The  ordinary  positions  of  the  mother  may  be  considered  in  this  connection 
to  be  three — the  vertical  position  of  the  trunk,  the  horizontal  position  in  a 
dorsal  decubitus,  and  the  horizontal  position  in  a  lateral  decubitus.     "When 


THE   MECHANISM    OF  LABOR.  469 

the  trunk  is  erect  the  anterior  uterine  wall  is  inclined  to  the  horizon  at  an 
angle  of  about  35°,  and  the  lowest  portion  of  the  uterine  cavity  is  to  be 
found  in  the  neighborhood  of  the  pubes.  Most  pregnant  women  are  in  this 
position — that  is,  either  standing  or  sitting— for  about  two-thirds  of  the  twenty- 
four  hours,  and  it  is  consequently  the  most  important  of  the  three  positions  in 
this  connection.  In  this  position  of  the  mother  the  child  would  tend  to  assume, 
under  the  influence  of  gravity,  precisely  the  position  in  which  it  is  usually 
found — that  is,  a  vertex  presentation,  O.  L.  A. — and  in  the  absence  of  disturbing 
elements  it  will  be  in  this  relation  to  the  mother  about  two-thirds  of  the  time. 

When  the  woman  lies  upon  her  back  the  posterior  uterine  wall  is  inclined 
to  the  horizon  at  an  angle  of  about  55°,  and  the  lowest  portion  of  the 
uterus  is  in  the  neighborhood  of  the  promontory.  Thus,  in  this  position  also 
the  influence  of  gravity  tends  to  maintain  a  cephalic  presentation.* 

When  the  woman  lies  upon  her  side  the  lowest  point  of  the  uterine  cavity 
is  usually  near  the  fundus  and  toward  the  side  upon  which  she  reclines,  f  In 
this  position,  then,  the  influence  of  gravity  would  be  exerted  against  the 
maintenance  of  a  cephalic  presentation  ;  and  since  the  lateral  decubitus  is 
maintained  by  most  pregnant  women  for  the  greater  part  of  that  third  of 
their  time  which  is  spent  in  bed,  it  is  evident  that  the  influence  of  gravity 
would  not,  by  itself,  be  a  sufficient  cause  for  the  appearance  of  a  cephalic 
presentation  in  so  large  a  number  as  ninety-seven  out  of  every  one  hundred 
labors ;  but  since,  from  the  influence  of  gravity  alone,  it  is  probable  that  the 
head  would  maintain,  other  influences  being  excluded,  a  cephalic  presentation 
during  the  greater  part  of  the  time,  it  is  fair  to  assume  that  this  furnishes  a 
predisposition  toward  the  existence  of  a  cephalic  presentation  in  any  given 
case.  When,  moreover,  we  investigate  the  relation  of  this  factor  to  the  varia- 
tion in  percentages  due  to  premature  births  and  stillbirths,  we  find  its  influ- 
ence so  entirely  in  accord  with  the  results  of  clinical  observation  as  to  add 
still  further  proof  of  its  importance.  Thus,  Dr.  Duncan  found  that  when  a 
child  dies  in  utero  before  labor,  the  specific  gravity  of  its  head  is  less  than 
that  of  a  living  child,  and  the  body,  when  uncontrolled,  often  actually  floats 
head  uppermost  in  a  saline  fluid.  Again,  it  is  highly  probable  that  the  rela- 
tive difference  between  the  specific  gravity  of  the  head  and  that  of  the  body 
is  less  among  premature  than  among  full-term  children,  since  we  know  that 
the  proportionate  development  of  the  brain  and  the  cranial  bones,  in  compari- 
son with  that  of  the  body,  is  much  less  during  the  early  months  of  pregnancy 
than  it  becomes  at  term. 

It  may  with  propriety  be  conceded  that  the  greater  specific  gravity  of  the 
cephalic  pole  of  the  fetus  is  a  predisposing  cause  of  head  presentations,  and  it 
only  remains  to  be  determined  whether  the  other  causes  are  sufficient  to  main- 
tain this  position  when  once  established. 

*  Though  with  the  back  of  the  fetus  toward  the  back  of  the  mother  (see  Etiology  of  Posi- 
tion, p.  472). 

t  When  the  woman  lies  upon  her  right  side  the  influence  of  gravity  tends  to  turn  the  back 
of  the  child  forward,  and  when  she  lies  upon  her  left  side  tends  to  turn  it  backward. 


470  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

Adaptation  between  Fetus  and  Uterus. — It  is  usual  to  consider  the  uterus 
as  a  flaccid  mass  which  readily  moulds  itself  to  the  shape  of  its  contents  or  its 
surroundings ;  but  when  we  remember  that  during  each  contraction  the  uterus 
straightens  itself  and  tends  to  assume  a  definite  form,  and  that,  moreover, 
there  is  undoubtedly  a  process  of  slight  rhythmic  contraction  goiug  on  through- 
out the  whole  of  the  latter  part  of  pregnancy,  it  is  evident  that  the  uterus 
must  be  regarded  as  a  body  which  has,  to  some  extent  at  least,  a  definite,  in- 
trinsic shape.  It  has,  moreover,  been  determined  by  post-mortem  examina- 
tions that  this  shape  is  one  which  alters,  and  alters  in  a  definite  direction, 
during  the  development  of  the  uterus. 

At  and  for  some  time  before  the  fifth  month  the  uterine  cavity  is  nearly 
spherical  (Fig.  235),  and  is  very  large  as  compared  with  the  still  small  and 
undeveloped  fetus  ;  but  from  this  time  on  the  cavity  becomes  progressively 


Fig.  235. ^-Relative  size  of  the  fetus  and  the  uterine        Fig.  23fi.— Adaptation  between  the  uterus  and  the 
cavity  at  the  fifth  month.         >  fetus  at  term  in  vertex  presentation. 

more  and  more  pyriform,  until  toward  the  end  of  pregnancy  it  assumes  the 
definitely  pyriform  shape  shown  in  Figure  236.  The  uterine  cavity,  at  term 
and  under  normal  conditions,  is  but  little  larger  than  the  fetus. 

It  is,  moreover,  evident,  on  comparing  the  shape  of  the  fetus  in  its  ordinary 
attitude  with  the  shape  of  the  uterus  at  term,  that  in  head  presentations  (Fig. 
236)  the  fetus  and  the  uterus  are  extremely  well  adapted  to  each  other,  but 
that  in  breech  (Fig.  237)  or  in  transverse  presentations  one  portion  of  the 
uterine  muscle  is  subjected  to  an  undue  a-mount  of  tension,  while  other  por- 
tions are  unduly  relaxed;  therefore  any  change  from  the  cephalic  to  either  a 
breech  or  a  transverse  presentation  will  be  opposed  by  the  contractile  power* 
of  that  portion  of  the  uterine  muscle  that  would  be  overstretched  in  the  new 
presentations ;  that  is,  we  may  assume  that  the  shape  and  contractility  of  the 
uterine  walls  tend  to  preserve  a  cephalic  presentation  when  this  is  once  well 
established,  and  that  the  rhythmical  contractions  would  probably  tend  to  re- 
establish it  when  lost.  It  is  safe  to  assume,  then,  that  the  shape  of  the  uterus 
may  be  considered  an  important  factor  in  preserving  a  cephalic  presentation 


THE   MECHANISM  OF  LABOR. 


471 


Fig.  237.— Adaptation  between  the  fetus  and  the 
uterus  at  term  in  breech  presentation. 

First,  that  cephalic  presentations  pre- 


when  this  has  once  been  established  by  the  influence  of  gravity,  and  that  its 
insensible  contractions  furnish  an  influence  of  importance  in  re-establishing  a 
head  presentation  when  this  has  been  lost. 

Influence  of  the  Fetal  Movements. — Since  the  fetal  movements  are  accidental 
and  independent  of  any  volitional  impulse,  it  is  probable  that  their  occurrence 
would  be  insufficient  to  effect  any  con- 
siderable change  in  the  relation  of  the 
fetus  to  the  uterus  unless  in  an  ex- 
tremely relaxed  condition  of  the  uterine 
and  abdominal  walls,  and  that  even  in 
such  uteri  the  change  would  be  likely 
to  occur  only  when  the  position  of  the 
mother  added  the  influence  of  gravity 
to  the  effect  of  fetal  movements.  It  is 
evident  that  even  in  such  cases  the 
operation  of  the  same  causes  would 
probably  tend  to  a  speedy  assumption 
of  the  cephalic  presentation. 

Conclusions. — Tt  is  now  necessary  to 
consider  how  far  the  conditions  just 
enumerated  explain  the  observed  facts 
quoted  at  the  beginning  of  this  section  : 
ponderate  in  the  proportion  of  97  to  3;  second,  that  this  preponderance  is 
much  decreased  by  both  premature  deliveries  and  stillbirths ;  third,  that  the 
change  from  a  pelvic  or  a  transverse  presentation  into  a  cephalic  is  very  much 
more  common  than  the  loss  of  a  cephalic  presentation ;  and  fourth,  that  both 
abnormal  presentations  and  changes  of  presentation  are  much  commoiverV 
among  multipara  and   when  the  quantity  of  liquor  amnii  is  large.  >// 

First. — The  existence  of  a  condition,  the  influence  of  gravity,  that  tends 
to  establish  a  cephalic  presentation,  and  that  is  operative  for  two-thirds  of  the 
time,  in  combination  with  other  conditions  which  render  any  other  presentation 
unstable,  and  which  are  operative  all  the  time,  is,  in  the  absence  of  anything 
which  favors  any  other  presentation,  sufficient  to  account  for  almost  any  per- 
centage of  preponderance  of  cephalic  presentations. 

Second  and  Third. — In  the  middle  of  pregnancy  the  shape  of  the  uterine 
cavity  is  nearly  spherical  and  its  size  is  greatest  as  compared  with  that  of  the 
fetus ;  the  latter  is  but  little  developed  and  the  presentations  are  totally  un- 
certain. During  the  sixth  and  seventh  months  the  conditions  approach  nearer 
to  those  observed  at  term ;  but  even  in  the  eighth  and  ninth  months  the  differ- 
ence in  the  specific  gravity  of  the  cephalic  and  pelvic  ends  of  the  infant  is 
less  marked  than  at  term  ;  the  pyriform  shape  of  the  uterus  is  less  strongly 
marked,  and  the  adaptation  between  the  uterus  and  the  fetus  is  less  close ; 
that  is,  all  the  factors  which  we  have  been  considering  as  important  in  the 
production  of  the  preponderance  of  cephalic  presentations  have  less  value  than 
at  term.     We  find  by  observation  that  at  these  periods  the  preponderance  of 


472  AMERICAN  TEXT-BOOK   OF   OBSTETRICS. 

cephalic  presentations  is  correspondingly  decreased,  and  that  spontaneous 
changes  of  presentation  are  correspondingly  much  more  frequent  than  at  the 
end  of  pregnancy;  we  are,  then,  justified  in  our  belief  in  the  importance  of 
these  factors. 

Fourth. — These  considerations  are  in  full  accord  with  the  observed  fact  that 
both  abnormal  presentations  and  changes  of  presentation  occur  most  frequently 
in  multiparas  with  relaxed  uterine  and  abdominal  walls,  and  are  but  rarely 
seen  in  the  more  rigid  condition  of  the  muscles  that  is  characteristic  of  first 
pregnancies.  So,  too,  it  is  fully  established  that  these  changes  and  abnormal 
presentations  occur  much  more  frequently  when  the  quantity  of  liquor  amnii 
is  relatively  so  great  that  the  uterus  tends  through  distention  to  acquire  a 
more  nearly  spherical  shape,  and  when  the  limbs  of  the  fetus  are  accorded 
much  greater  freedom  of  movement. 

As  a  result,  it  seems  safe  to  assume  that  the  influence  of  the  relatively 
greater  specific  gravity  of  the  cephalic  pole  of  the  fetus  is  the  predisposing 
cause,  and  that  this,  together  with  the  intrinsic  shape  of  the  uterine  cavity 
and  the  influence  of  the  movements  of  the  fetus,  are  the  maintaining  causes 
of  the  great  preponderance  of  cephalic  presentations. 

Etiology  of  Position. — It  has  already  been  observed  (p.  469)  that  in  the 
erect  posture  of  the  trunk,  usually  assumed  by  the  woman  for  two-thirds  of 
the  twenty-four  hours,  the  influence  of  gravity  tends  to  the  production  of 
an  O.  L.  A.  position,  and  in  the  remaining  one-third  of  the  twenty-four  hours 
the  influence  of  gravity  varies  with  the  decubitus  which  the  woman  assumes 
in  bed.  Therefore  it  may  safely  be  assumed  that  any  conservative  factors 
which  appear  late  and  tend  to  fix  the  child  in  any  position  in  which  they 
find  it  are  more  likely  to  find  it  O.  L.  A.  than  in  any  other  position.  Such  a 
factor  is  to  be  found  in  the  shape  of  the  superior  strait.  The  presence  of  the 
rectum  in  the  left  ilio-sacral  notch  renders  the  second  oblique  diameter  of  the 
pelvis  less  ample  than  the  first,  so  that  if  the  oblique  cross-section  of  the  head 
that  is  ordinarily  presented  to  the  pelvis  at  the  inlet  rests  with  its  long  diam- 
eter in  correspondence  with  the  second  oblique  diameter  at  the  brim,  the  head 
is  less  easily  accommodated  than  if  it  is  presented  to  the  first  oblique  diameter. 
It  will,  then,  as  the  adaptation  becomes  progressively  tighter  and  tighter,  tend 
to  remain  in  the  first  oblique  diameter  for  longer  periods  than  in  the  second  ; 
that  is,  it  will  be  dislodged  with  difficulty  from  the  first  oblique  diameter,  and 
with  ease  from  the  second  by  any  slight  cause ;  and  since  the  influence  of 
gravity  tends  during  the  greater  part  of  the  time  to  turn  the  occiput  forward, 
a  head  which  occupies  either  an  O.  D.  A.  or  an  O.  L.  P.  position  will  tend  to, 
become  O.  L.  A.  rather  than  anything  else.  The  maintenance  of  an  O.  D.  P. 
position  is,  moreover,  rendered  comparatively  unlikely  from  the  fact  that  the 
shape  of  the  head  is  less  well  adapted  to  that  of  the  pelvis  in  this  position 
Changes  of  position  are,  in  fact,  extremely  frequent  until  within  the  last  few 
weeks  before  delivery,  and  the  position,  moreover,  is  never  finally  determined 
until  the  head  engages  at  the  brim. 

Diagnosis. — On  abdominal  examination  the  head  is  found  at  the  inlet ;  the 


THE   MECHANISM    OF  LABOR.  473 

fetal  limbs  and  the  most  accessible  end  of  the  head  are  found  on  one  side  of 
the  abdomen,  and  the  heart  on  the  other.  On  vaginal  examination  the  finger 
should  recognize  the  small  fontanelle  on  one  side  of  the  pelvis,  and  by  follow- 
ing the  sagittal  suture  should  find  the  large  fontanelle  on  the  other.  The  ears 
should  always,  and  the  mastoids  and  lateral  fontanelles  should  usually,  be 
felt  at  the  ends  of  the  lambdoidal  sutures. 

Prognosis. — The  prognosis  for  both  mother  and  child  is  better  than  in  any 
other  variety  of  labor. 

A.  Mechanism  of  the  First  Stage  of  Labor. 

It  is  customary  to  divide  labor  into  three  stages.  The  first  stage  comprises 
the  time  occupied  in  the  dilatation  of  the  os ;  the  second,  that  expended  in  the 
descent  and  expulsion  of  the  child  ;  while  the  third  is  occupied  by  the  birth 
of  the  placenta. 

For  purposes  of  description  it  is  well  to  consider  the  three  stages  as  being 
sharply  divided  from  one  another,  but  it  must  be  remembered  that  clinically 
the  division  between  the  first  and  second  stages  is  often  difficult  and  indefinite, 
since  the  final  stages  of  dilatation  are  not  infrequently  accomplished  only 
during  the  descent  of  the  head ;  and  for  clinical  purposes  it  is  well  to  define 
the  end  of  the  first  stage  as  occurring  whenever  the  os  is  fully  dilated  or  dilat- 
able, it  being  understood  that  the  expression  "  fully  dilatable"  refers  to  a  con- 
dition in  which  the  os,  though  still  imperfectly  dilated,  has  become  so  soft  and 
elastic  as  not  to  offer  any  efficient  obstacle  to  the  descent  of  the  presenting  part. 

To  understand  exactly  the  mechanism  of  labor  it  is  necessary  to  discuss 
first  the  forces  by  which  the  process  is  accomplished,  and  next  the  manner  in 
which  each  force  acts  during  the  different  stages  of  labor. 

The  forces  by  which  labor  is  effected  are  those  produced  by  the  contraction 
of  the  uterine  and  abdominal  muscles,  together  with  such  influence  as  can  be 
effected  by  the  weight  of  the  child  and  the  waters. 

The  uterine  muscle  acts  in  two  ways:  first,  by  diminishing  the  intra-uterine 
area  and  thus  creating  a  general  intra-uterine  fluid-pressure  due  to  the  contrac- 
tion of  the  uterus  upon  the  fluid  contents  of  the  unruptured  ovum  ;  second,  by 
the  force  of  direct  contact  between  the  breech  and  the  fundus  of  t\w.  uterus 
whenever  a  rupture  of  the  membranes  and  the  consequent  escape  of  the  waters 
permit  this  contact  to  occur.  Direct  contact  may  also  occasionally  occur,  as 
will  be  seen  later,  before  the  rupture  of  the  membranes. 

The  abdominal  muscles  when  set  into  voluntary  contraction  reinforce  both 
forms  of  action  of  the  uterine  muscle.  When  the  uterine  muscle  is  in  direct 
contact  with  the  breech,  the  abdominal  muscles,  lying  in  close  contact  with  the 
uterus,  add  their  force  to  that  which  the  uterus  itself  exerts  against  the  child  ; 
when  the  child  is  protected  from  contact  with  the  uterine  walls  by  the  presence 
of  a  quantity  of  liquor  amnii,  the  contraction  of  the  abdominal  muscles  again 
adds  itself  to  that  of  the  uterine  wall,  and  thus  adds  its  increment  to  the 
general  intra-uterine  fluid-pressure.  The  force  of  gravity  is  inactive  in  many 
positions  of  the  mother,  and  is  at  most  an  increment  of  but  small  importance. 


474 


AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 


B-&, 


In  considering  the  manner  in  which  the  above-mentioned  forces  are  employed 
in  effecting  the  dilatation  of  the  os  during  the  first  stage  of  labor,  it  is  neces- 
sary to  consider  several  variations  which  may  occur  in  the  mechanical  con- 
ditions. When  the  waters  are  abundant  and  the  membranes  persist  unbroken 
throughout  the  first  stage,  the  dilatation  is  usually  accomplished  by  the  action 
of  the  membranes  only.  This  may  be  considered  the  normal  mechanism  of 
dilatation,  and  must  be  described  first,  after  which  it  will  be  proper  to  take 
up  the  various  conditions  in  which,  from  one  cause  or  another,  the  membranes 
cease  to  act  their  proper  part,  and  the  dilatation  must  be  accomplished  by  the 
pressure  of  the  fetal  head  against  the  cervix. 

Normal  Mechanism  of  Dilatation. — In  the  first  instance — that  is,  when 
the  waters  are  abundant  and  the  membranes  are  intact — the  position  of  the 

fetus  is  unaffected  by  the  intra-uterine 
fluid-pressure.  It  is  an  axiom  in  phys- 
ics that  fluid-pressures,  however  pro- 
duced, are  invariably  equal  and  oppo- 
site in  all  directions,  from  which  it  fal- 
lows that,  the  pressures  A  (Fig.  238) 
being  equal  and  opposite  to  the  pres- 
sures jB,  the  child  will  be  unmoved  by 
the  uterine  contraction.  Similarly,  the 
fluid-pressure  upon  any  one  portion  of 
the  uterine  wall  being  equal  to  that  ex- 
erted upon  any  other  portion  of  equal 
area,  there  would  be  no  effect,  even 
upon  the  shape  of  the  uterus,  if  its 
entire  surface  contracted  at  once  and 
it'  its  walls  were  of  uniform  strength 
throughout.  The  initial  stages  of  dila- 
tation of  the  os  are  in  reality  to  be 
referred  to  the  fact  that  the  lower 
uterine  segment  possesses  less  muscular 
strength  than  the  upper  part  of  the  uterus,  and  to  the  character  of  the  uterine 
contractions.  Neglecting  for  the  moment  the  latter  factor,  and  limiting  the 
discussion  to  the  effect  of  the  different  strengths  of  the  upper  and  lower  uterine 
segments,  we  shall  see  that  the  contraction  of  the  more  powerful  upper  part  of 
the  uterus  forces  the  less  powerful  lower  portion  open,  notwithstanding  its 
efforts  at  contraction. 

The  total  force  exerted  by  the  uterine  contractions  results  in  the  application 
of  a  uniform  centrifugal  pressure  upon  all  portions  of  the  containing  wall. 
The  amount  of  this  pressure  upon  any  given  unit  of  surface — as,  for  example, 
a  square  inch — will,  of  necessity,  be  equal  to  the  average  force  exerted  by  the 
same  superficial  extent  of  the  uterine  wall ;  hence  it  follows  that  at  any  portion 
of  the  viscus  where  the  strength  of  the  wall  is  greater  than  the  average  the 
contracting  centripetal  force  will  tend  to  overcome  the  resulting  centrifugal 


Fig.  238.— Diagram  illustrating  the  absence 
of  alteration  in  the  attitude  of  a  child  by  the 
action  of  opposite  and  equal  fluid-pressures. 


THE   MECHANISM    OF   LABOR. 


475 


force,  and  the.  result  will  be  a  decrease  in  the  extent  of  the  uterine  walls  at 
that  point.  Similarly,  at  any  point  where  the  strength  of  the  uterine  wall  is 
below  the  average  the  expanding  centrifugal  force  of  the  fluid-pressure  will 
be  greater  than  the  centripetal  force  of  the  contracting  muscles,  and  at  such 
points,  therefore,  the  expanding  force  of  the  fluid-pressure  will  tend  to  over- 
come the  contracting  force  of  the  uterine  muscles,  and  there  will  be  a  conse- 
quent increase  in  the  area  of  those  portions  of  the  uterine  wall.  Xow,  the 
lower  uterine  segment  is  by  all  odds  weaker  than  any  other  portion  of  the 
uterus ;  it  therefore  tends  to  expand  during  the  contraction  from  the  action  of 
the  general  intra-uterine  fluid-pressure. 

The  circular  portion  of  the  uterine  area,  which  is  opposite  to  the  lumen  of 
the  vagina,  is,  moreover,  unsupported  by  the  general  intra-abdominal  pressure 
and  by  the  force  of  the  tonicity  of  the 
abdominal  muscles  that  is  exerted  upon 
all  the  other  portions  of  the  uterus — a 
fact  which,  by  decreasing  the  centripetal 
force,  still  further  increases  the  surplus 
of  the  centrifugal  element  at  this  point. 
As  a  matter  of  fact,  at  the  beginning  of 
labor  the  first  influence  of  the  uterine 
contractions  is  seen  in  the  assumption 
by  the  lower  uterine  segment  of  a  more 
expanded  shape,  such  as  shown  by  the 
dotted  outline  in  Figure  239.  Moreover, 
since  at  one  point  in  the  lower  uterine 
segment  the  cohesion  of  its  substance 
is  still  further  lessened  by  the  existence 
of  a  solution  of  continuity,  the  lumen 
of  the  os  uteri,  it  is  evident  that  there 
will  be  a  still  more  marked  tendency 
to  expansion  at  this  weakest  spot,  resulting  in  a  tendency  to  dilatation  of 
the  os. 

To  these  considerations  must  be  added  the  effect  of  the  peculiar  composition 
of  the  uterine  muscle  and  of  the  peculiar  character  of  its  contractions.  It  is 
essential  to  remember  that  this  highly  composite  muscle  is  made  up  of  inter- 
lacing fibres,  whose  action  may  mechanically  be  divided  into  one  set  of 
longitudinal  and  one  of  circular  stresses ;  that  is,  if  the  action  of  those  fibres 
having  an  oblique  direction  be  resolved,  as  is  physically  allowable  and  proper, 
into  their  longitudinal  and  transverse  resultants,  the  action  of  the  whole  will 
be  found  precisely  equal  to  that  which  would  be  exerted  by  two  hypothetical 
sets  of  fibres,  of  which  the  first  and  most  powerful  set  directly  encircle  the  ute- 
rus in  horizontal  zones,  while  the  second  and  less  powerful  set  extend  upward 
through  the  margin  of  the  os,  cross  the  fundus,  and  thence  pass  down  to 
reach  the  margins  of  the  os  at  points  opposite  to  their  origins. 

If  a  uterine  muscle  so  composed  were  set  into  action,  it  will  be  seen  that, 


Fig.  239.— Diagrams  showing  the  diminution 
of  the  upper  uterine  segment  and  the  expansion 
of  the  lower  segment  during  each  contraction. 


476 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


from  a  mechanical  standpoint,  the  circular  fibres  surrounding  the  os  would  by 
their  contraction  tend  to  keep  it  closed,  while  the  longitudinal  fibres,  acting  in 
opposition  to  these,  would  by  their  contraction  tend  to  open  the  os  by  drawing 
its  margins  apart  over  the  contained  ovum.  This  conception,  though  some- 
what more  simple  than  the  actual  auatomical  fact,  is  mechanically  essentially 
coi-rect ;  but,  since  the  circular  stresses  are  the  more  powerful,  it  is  evident 
that  this  arrangement  cannot  result  in  the  dilatation  of  the  os  unless  compli- 
cated by  the  presence  of  some  additional  factor.  This  factor  is  found  in  the 
circumstance  that  the  contractions  of  the  uterine  muscles,  like  those  of  all  the 
hollow  viscera  of  the  body,  are  peristaltic,  and  that  the  rhythmic  contraction 
of  the  uterus  begins  at  the  fundus  and  passes  gradually  down  to  the  cervix. 
Each  contraction  of  a  given  part  of  the  uterus  is  preceded  and  followed  by  a 
relaxation  ;  but  since,  from  the  interlaced  arrangement  of  the  fibres  of  the 
uterus,  the  contraction  of  any  portion  of  its  surface  necessarily  exerts  a  longi- 
tudinal strain,  it  will  be  found  that  the  outward  stress  upon  the  margius  of 
the  os  remains  nearly  constant,  while  its  circular  contraction  is  intermittent;  it 
is  probable  that  the  initial  dilatation  of  the  os  is  largely  due  to  the  constancy 
of  the  longitudinal  and  the  intermittency  of  the  circular  strain  ;  that  is,  the 
first  gains  in  dilatation  are  made  at  moments  when  the  uterine  muscles  of  the 
lower  uterine  segment  and  the  cervix  are  relaxed,  but  when  the  general  fluid- 
pressure  is  maintained  by  contractions  of  the  upper  portions  of  the  uterus. 

As  the  iuterual  os  and  the  upper  portion  of  the  cervix  dilate  under  the 
action  of  these  forces,  a  new  mechanism  comes  into  play  through  the  elasticity 
of  the  membranes,  which  bulge  through  the  circle  of  the  os  and  enable  the 
intra-uterine  fluid-pressure  to  take  direct  effect  upon  its  margins.  As  this 
process  continues  the  internal  os  becomes  effaced,  the  cervix  is  shortened  and 


Fig.  240. — Diagram  illustrating  the  dilatation 
of  the  os  by  the  membranes.  If  the  application  of 
the  fluid-pressure  to  the  os  (at  right  angles  to  the 
surface  of  the  membranes  at  this  point)  is  repre- 
sented by  the  direction  of  the  arrow,  and  the 
amount  of  the  force  by  the  length  of  the  diagonal 
line  which  continues  the  arrow,  the  amount  of 
force  that  is  applicable  to  the  dilatation  of  the  os 
is  represented  by  the  length  of  the  line  A. 


Fig.  241.— Diagram  illustrating  the  dilata- 
tion of  the  os  by  the  membranes.  All  the  con- 
ditions are  identical  with  those  of  Figure  237,  ex- 
cept that  the  membranes  have  a  greater  con- 
vexity ;  the  direction  of  the  arrow  is  therefore 
more  oblique,  and  the  force  efficient  for  dila- 
tation, represented  by  the  line  A,  is  greatly  in- 
creased. 


disappears,  and  finally  the  external  os  itself  is  in  direct  contact  with  the  mem- 
branes and  begins  to  receive  directly  the  effect  of  the  longitudinal  stresses.  As 
the  external  os  dilates  the  membranes  again  bulge  forward  into  its  lumeu,  and 
the  force  of  the  fluid-pressure  becomes  directly  active  upon  its  margins.  The 
force  so  exerted  is  directly  proportional  to  the  convexity  of  the  membranes, 
and  increases  as  the  convexity  increases — a  fact  which  is  explainable  by  well- 


THE   MECHANISM    OF   LABOR.  477 

known  physical  laws  as  follows :  The  force  of  fluid-pressure,  in  addition  to 
being  opposite  and  equal  at  all  points,  is  always  exerted  at  right  angles  to 
any  surface  against  which  it  is  applied.  If  it  is  necessary  to  ascertain  what 
portion  of  the  force  is  exerted  in  any  given  direction,  it  is  only  necessary  to 
break  up  the  internal  force  into  its  elements  by  the  construction  of  a  parallelo- 
gram of  forces,  such  as  is  described  in  all  elementary  treatises  on  mechanics  and 
illustrated  in  Figures  240  and  241.  Figure  240  exhibits  the  influence  of  the 
general  intra-uterine  fluid-pressure  when  the  conditions  of  the  case  allow  but  a 
slight  convexity  to  the  unsupported  portions  of  the  membranes.  The  expan- 
sive element  of  the  fluid-pressure  is  here  represented  by  the  line  A,  while  in 
Figure  241,  where  the  convexity  of  the  unsupported  membranes  is  much 
greater,  the  expansive  element  of  the  force  will  be  represented  by  the  length 
of  the  much  longer  line  A:  from  this  it  follows  that,  other  things  being  equal, 
the  rapidity  of  dilatation  will  be  proportional  to  the  degree  to  which  the  mem- 
branes project  through  the  os.  As  will  be  seen  later,  the  same  considerations 
are  equally  applicable  to  the  action  of  the  head  in  producing  dilatation  after 
the  rupture  of  the  membranes.  The  familiar  clinical  fact  that  the  closing 
stages  of  dilatation  are  usually  much  more  rapid  than  the  beginning  stages  is 
fully  explained  by  the  foregoing  considerations,  taken  in  connection  -with  the 
equally  familiar  fact  that  the  contractions  of  the  uterus  tend  normally  to 
become  stronger  and  stronger  throughout  the  process  of  labor. 

In  the  more  normal  form  of  the  mechanism  of  the  first  stage — that  is,  so 
long  as  the  membranes  remain  intact — the  progress  of  the  first  stage  of  labor 
is  dependent  mainly  upon  the  first  form  of  force  which  the  uterine  muscle  is 
capable  of  exerting— that  is,  the  force  of  the  general  intra-uterine  fluid-pres- 
sure— and  the  membranes  are  the  dilating  agent. 

The  second  form  of  force,  that  of  the  direct  pressure  of  the  uterine  muscle 
against  the  child,  is  under  these  circumstances  inoperative,  while  the  fact  that 
the  voluntary  muscles  of  the  abdominal  walls  are  but  seldom  brought  into 
play  by  the  patient  reduces  the  action  of  the  remaining  or  auxiliary  forces,  in 
this  form  of  the  mechanism  of  the  first  stage,  to  the  small  reinforcement  of 
the  general  intra-uterine  fluid-pressure,  which  is  due  to  the  general  intra- 
abdominal pressure  constantly  exerted  by  the  tonicity  of  these  muscles. 

Mechanism  of  Dilatation  of  the  Os  after  Rupture  of  the  Membranes, 
with  Partial  or  Complete  Escape  of  the  Waters. — Partial  Escape. — After 
the  rupture  of  the  membranes  the  liquor  amnii  tends  to  drain  away  until  its 
escape  is  stopped  by  the  contact  of  the  presenting  part  with  the  margins  of 
the  os  (Fig.  242).  Iu  this  condition  the  presenting  part  forms  with  the  circle 
of  the  os  a  ball-valve ;  the  geueral  intra-uterine  pressure  is  concentrated  upon 
its  upper  surface,  and  its  descent  is  opposed  only  by  the  comparatively  feeble 
resistance  of  the  cervix.  When  this  condition  occurs  the  portions  of  the 
fetus  that  correspond  with  arrows  marked  A'  and  B'  are  still  affected  by  pres- 
sures which  are  opposite  and  exactly  equal  to  the  propelling  force  exerted 
upon  the  portions  which  correspond  with  the  arrows  A  and  £,  but  the  propel- 
ling force  represented  by  the  arrow  C  is  opposed  only  by  the  resistance  of  the 


478 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


unsupported  cervical  and  vaginal  tissues,  against  which  the  head  is  pressed  by 
a  force  equal  to  the  effect  of  the  intra-uteriue  fluid-pressure   upon   an  area 


Fig.  242.— Diagram  illustrating  the  manner 
in  which  the  general  intra-uterine  fluid-pressure 
becomes  propulsive  after  the  rupture  of  the 
membranes. 


Fig.  243.— Diagram  illustrating  the  dilatation  of 
the  os  by  the  head.  The  total  force  is  again  repre- 
sented by  the  oblique  line,  and  the  force  which  is  ap- 
plicable for  dilatation  is  represented  by  the  line  A. 


equal  to  the  transverse  area  of  that  zone  of  the  uterus  where  the  head  first 

comes  in  contact  with  the  walls — that  is,  the  surface  R  to  R'. 

From  the  comparative  rigidity  of 
the  spherical  head  it  can  exert  but  little 
direct  expansive  force  upon  the  margins 
of  the  os  during  the  early  stages  of 
dilatation  (Fig.  243) — a  fact  which  ex- 
plains admirably  the  relatively  slow 
progress  of  dilatation  after  early  rup- 
ture of  the  membranes.  When,  how- 
ever, the  os  has  so  far  dilated  as  nearly 
to  admit  the  greatest  circumference  of 
the  head,  its  action  is  that  of  a  slightly 
tapering  wedge,  by  which  almost  the 
whole  power  of  the  propelling  force  is 
transmitted  into  an  outward  pressure 
of  the  margins  of  the  os,  and  which 
must  compel  an  extremely  rapid  com- 
pletion of  the  dilatation  *  (Fig.  244). 

It  will  be  seen  that  in  this  second  form  of  the  mechanism  of  the  first  stage 

the  force  employed  is  still  that  of  the  general  intra-uterine  fluid-pressure,  but 

that  the  dilating  agent  is  now  the  head. 

*  It   will   be  seen  that  this  fact  is  an  adequate  explanation  of  the  greater  frequency  of 

laceration  of  the  cervix  when  a  rupture  of  the   membranes  results  in  the  completion  of  the 

dilatation  by  the  direct  pressure  of  the  rigid  head. 


Fig.  244.— Diagram  illustrating  the  dilatation 
of  the  os  by  the  head.  The  total  force  is  repre- 
sented by  the  oblique  line,  and  the  force  applic- 
able for  dilatation  is  represented  by  the  line  A. 


THE   MECHANISM   OF  LABOR. 


479 


After  Complete  Escape  *  of  the  Waters. — The  escape  of  any  considerable 
quantity  of  the  waters  usually  results  in  contraction  of  the  uterus  sufficient  to 
permit  of  firm  contact  between  the  fundus  and  the  breech  of  the  child.  The 
force  of  this  contact  is  then  transmitted  to  the  head  through  the  vertebral 
column  of  the  fetus.  At  first  sight  it  seems  unlikely  that  any  considerable 
force  could  be  transmitted  through  so  flexible  a  rod  as  the  vertebral  column  of 
an  unborn  child.  This  transmission  is,  however,  rendered  possible  by  the 
following  conditions  :  It  is  an  observed  fact  that  during  a  contraction  the  long 
diameter  of  the  uterus,  far  from  being  decreased,  is  actually  lengthened.  This 
phenomenon  is  due  to  the  superior  strain  of  the  circular  stresses,  which  by 
their  greater  force  decrease  the  antero-posterior  diameter  of  the  uterus  and 
thereby  f  increase  its  length  (Figs.  245,  246) ;  the  lateral  uterine  walls,  at  the 


Fig.  245.— Diagram  illustrating  the  alteration 
in  the  shape  of  a  cross-section  of  a  uterus  during 
its  contractions.  The  heavy  line  represents  the 
non-contracted,  the  dotted  line  the  contracted, 
uterus  (compare  Fig.  243). 


Fig.  246.— Diagram  illustrating  the  alteration 
in  the  shape  of  a  sagittal  section  of  the  uterus 
during  its  contractions.  The  heavy  line  repre- 
sents the  non-contracted,  the  dotted  line  the  con- 
tracted, uterus. 


same  time,  come  into  strong  contact  with  the  surface  of  the  fetal  body,  and  so 
straighten  out  the  child,  thus  increasing  the  violence  of  the  contact  between 
the  breech  and  the  fundus,  and  affording  a  firm  supporting  surface  which  pre- 
vents any  bending  of  the  vertebra?,  and  converts  the  backbone  for  the  moment 
into  a  mechanically  rigid  rod  which  is  fully  capable  of  the  transmission  of 
force.  AVhen  this  form  of  mechanism  obtains,  the  head  acts  as  the  dilating 
wedge,  and  the  second  form  of  force,  that  furnished  by  direct  contact  between 
the  breech  and  the  fundus,  is  alone  active. 

Mechanism  of  Dilatation  of  the  Os  with  Originally  Scanty  Waters. — 
It  occasionally  happens  that  the  waters  are  originally  so  scanty  in  amount  as  to 
permit  direct  contact  between  the  breech  and  the  fundus  to  occur  early  in  the 
first  stage.  Under  these  circumstances  the  head  is  brought  into  close  contact 
with  the  os  at  the  beginning  of  labor.  The  mechanical  conditions  are  now 
closely  similar  to  those  which  obtain  after  the  escape  of  the  waters,  with  the 
single  exception  that  if  the  membz-anes  are  tough  and  inelastic  their  tension 
may  somewhat  impede  the  progress  of  the  head. 

*  This  term,  though  conventional,  is  inaccurate,  as  there  is  almost  always  some  liquor  left  in 
the  uterus. 

■f  The  ovum  being  incompressible. 


480 


AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 


Mechanism  of  Dilatation  with  Undue  Elasticity  of  the  Membranes. — 

If  the  membranes  are  unusually  elas- 
tic, it  may  sometimes  happen  that  after 
the  formation  of  a  considerable  pouch 
of  membranes  in  advance  of  the  head, 
the  volume  of  the  uterine  contents 
may  be  lessened  sufficiently  to  permit 
the  head  itself  to  be  brought  into  close 
contact  with  the  margins  of  the  os, 
by  the  force  of  a  perhaps  temporary 
direct  contact  between  the  breech  and 
the  fundus.  In  this  position,  if  the 
head  is  in  contact  with  the  entire  mar- 
gin of  the  os,  in  forms  with  it  a  ball- 
valve  by  which  the  "fore-waters"  are 
entirely  cut  off  from  the  uterine  con- 
tents. The  pressure,  C  (Fig.  247),  is 
now  opposed  only  by  the  elasticity  of  the 
membranes  and  of  the  vaginal  tissues. 
The  general  fluid-pressure  is  no  longer 
exerted  against  the  margins  of  the  os, 
and  the  conditions  are  mechanically  sim- 
ilar to  those  illustrated  in  Figure  242. 


Fig.  247.— Diagram  illustrating  the  formation 
of  a  ball-valve  by  contact  between  the  head  and 
the  edges  of  the  os.  The  waters  behind  the  head 
are  exposed  to  the  general  intra-uterine  fluid- 
pressure,  while  the  fluid-pressure  in  advance  of 
the  head  is  only  created  by  the  elasticity  of  the 
fetal  membranes. 


B.  Mechanism  of  the  Second  Stage  of  Labor  in  Vertex  Presentations, 

O.  L.  A. 

The  second  stage  of  labor  is  commonly  divided  into  three  sub-stages: 
The  descent  and  expulsiou  of  the  head  ;  external  restitution  ;  and  the  delivery 
of  the  trunk. 

The  adaptation  between  the  normal  head  and  the  pelvis  is  so  close  that  for 
the  accomplishment  of  the  descent  and  expulsion  of  the  head  there  is  required 
the  occurrence  of  a  set  of  somewhat  complicated  movements  which  are,  in  fact, 
essentially  one  single  complex  motion.  This  motion  consists  of  three  elements : 
(1)  The  descent  of  the  head  through  the  pelvis  ;  (2)  a  change  from  the  partially 
extended  position  which  the  head  normally  occupies  at  the  beginning  of  labor 
to  one  of  complete  flexion ;  and  (3)  lateral  rotation  of  the  head  within  the 
canal,  from  the  oblique  position  which  the  suboccipito-bregmatic  diameter 
occupies  at  the  brim  to  the  antero-posterior  position  in  which  it  emerges  from 
the  outlet.  Although  it  is  necessary  in  discussing  this  motion  to  describe  its 
components  separately,  it  must  not  be  forgotten  that  no  one  of  its  parts  can 
proceed  to  its  accomplishment  without  the  coexistence  of  the  others.  Thus, 
descent  can  be  accomplished  only  during  the  existence  of  flexion,  while  flexion 
is  produced  only  by  the  act  of  descent.  So,  too,  the  final  stage  of  descent, 
Known  as  expulsion,  is  normally  impossible  without  rotation,  while  rotation 
occurs  only  during  the  descent  of  a  fully-flexed  head.     The  most  intelligible 


THE    MECHANISM    OF  LABOR.  481 

way  of  describing  these  highly  complex  phenomena  is  by  a  chronological  study 
of  the  mechanical  conditions  which  occur  and  succeed  each  other  during  the 
stage  of  descent  and  expulsion. 

Descent. — It  is  necessary,  in  describing  the  mechanism  of  the  second  stage, 
to  begin  by  considering  the  action  of  the  forces  by  which  the  mechanism  of 
this  stage  is  effected.  So  long  as  the  fetus  is  exposed  on  all  sides  to  contact 
with  the  liquor  amnii,  the  contractions  of  the  uterine  and  abdominal  muscles 
can  produce  no  effect  upon  it  other  than  that  of  subjecting  it  to  a  uniform 
fluid-pressure,  equal  and  opposite  in  all  directions.  In  point  of  fact,  the  mech- 
anism of  descent  does  not  begin  until  the  presenting  part  is  cut  off  from  the 
liquor  amnii  by  coming  into  apposition  with  the  edges  of  the  os.  As  was 
implied  in  the  last  section,  this  contact  may  happen  in  either  of  two  ways : 

First :  When  the  mechanism  of  the  first  stage  is  such  that  the  head  comes 
into  close  contact  with  the  margins  of  the  os  before  any  considerable  quantity 
of  the  liquor  amnii  has  escaped  from  the  uterus,  it  forms  with  the  os  a  ball- 
valve  (Figs.  244  and  247)  by  which  the  remaining  part  of  the  waters  is 
retained  within  the  uterus  ;  and  the  occiu'rence  of  descent  is  then  the  result 
of  the  action  of  the  intra-uterine  fluid-pressure.  This  is  the  normal — that  is, 
the  most  usual  and  the  most  favorable — mechanism  of  descent. 

Second :  When  close  contact  between  the  head  and  the  os  does  not  occur 
until  after  the  complete  escape  of  the  waters,  the  uterine  muscle  contracts 
upon  the  child,  and  the  force  of  the  circular  stresses  is  lost  so  far  as  the  pro- 
duction of  descent  is  concerned,  but  the  breech  and  the  fundus  of  the  uterus 
come  into  contact  with  each  other,  and  the  force  of  the  longitudinal  stresses  is 
tli us  still  available.  This  second  form  of  the  mechanism  of  the  second  stage 
is  commonly  called  a  "  dry  labor,"  and  such  labors  are,  with  reason,  much 
dreaded  by  obstetricians,  because  the  loss  of  the  powerful  circular  stresses 
usually  leads  to  a  protracted  second  stage.  * 

Normal  Mechanism  of  Descent. — The  portion  of  the  head  that  is  without 
the  uterus  (E,  72',  Fig.  242)  is  opposed  only  by  the  resistance  of  the  vaginal 
tissues.  Every  other  portion  of  the  fetus  is  exposed  to  the  general  intra-uterine 
fluid-pressure.  If  it  is  remembered  that  fluid-pressures  are  always  equal  and 
opposite,  it  will  be  seen  that  the  forces  A  and  B  are  directly  neutralized  by  the 
forces  A'  and  B',  and  that  the  force  C  is  opposed  only  by  the  comparatively 
trifling  resistance  of  the  vaginal  tissues.  This  force  (C)  is  then  practically 
unopposed,  and  is  therefore  efficient  for  descent. 

Mechanism  of  Descent  in  Dry  Labors. — When  the  escape  of  the  waters  has 
permitted  the  uterus  to  contract  upon  the  child,  the  advance  of  the  present- 
ing part  is  opposed  only  by  the  vaginal  tissues,  and  is  favored  by  the  force 
of  all  the  longitudinal  stresses  of  the  uterine  muscle  ;f  but  unless  the  descent 
progresses  rapidly  a  localized  contraction,  due  to  the  unopposed  action  of 
the  circular  stresses,  leads  to  a  lessening  of  the  calibre  of  the  uterine  canal 
at  any  point  where  the  diameter  of  the  child  is  small — for  example,  the  neck 
(Fig.  248) — and  the  descent  of  the  child  is  then  further  opposed  by  the  fact 

*  Consult  Mechanism  of  Descent  in  Dry  Labors  for  other  factors  of  delay. 
t  And  by  the  auxiliary  efforts  of  the  abdominal  muscles. 


482  AMERICAN    TEXT- BOOK    OF    OBSTETRICS. 

that  the  shoulders  must  be  made  to  dilate  this  ring — that  is,  to  overcome  the 
tonic  contraction  of  the  circular  stresses.  In  dry  labors,  then,  the  force  of  the 
circular  stresses  is  not  only  lost  as  a  factor  in  the  production  of  descent,  but 
may  sometimes  also  be  opposed  to  it. 

Flexion. — At  first  sight  it  would  seem  that  the  only  result  to  be  expected 
in  either  case  would  be  the  occurrence  of  descent,  and  that  as  the  head  is 
normally  somewhat  extended  at  the  beginning  of  labor,  this  descent  would 
oppose  to  the  pelvic  diameters  the  always  difficult  and  frequently  impossible 
occipitofrontal  diameter.  A  somewhat  more  careful  examination  will  demon- 
strate, however,  that  the  propelling  and  opposing  forces  are  already  so  dis- 
posed upon  the  head  as  to  favor,  from  the  start,  the  occurrence  of  flexion,  and 
that  the  first  movement  of  descent  will,  under  normal  circumstances,  tend  to 
bring  to  the  brim  the  much  smaller  suboceipito-bregmatic  diameter.  To  this 
end  two  factors  contribute  :  first  and  most  important,  the  articulation  of  the 


1  '     i 

1     ■/ 


x&. 


■s^ 


Fig.  248.— Constriction-ring  about  the  neck  of  the  child  Fig.  249.— Diagram  of  head  lever, 

(one-sixth  natural  size). 

vertebral  column  to  the  skull  at  a  point  much  nearer  to  the  occipital  than  to 
the  frontal  end  of  the  head  ;  second,  the  mechanical  effects  of  the  irregular 
shape  of  the  skull. 

Unequal  Lengths  of  the  Ends  of  the  Head. — The  effects  of  the  excentric 
position  of  the  occipito-atlantoid  articulation  must  be  investigated  separately 
for  each  of  the  three  forms  of  force  that  may  be  active — that  is,  for  the  force 
of  gravity,  the  general  fluid-pressure,  and  the  force  of  direct  contact  with  the 
uterine  muscle. 

Force  of  Gravity. — Whenever  the  force  of  gravity  is  active,  it  is  evi- 
dent that  the  weight  of  the  body  will  be  transmitted  to  the  skull  through 
the  occipito-atlantoid  articulation.  If  the  fetal  head  is  supposed,  at  the  begin- 
ning of  this  motion,  to  occupy  a  position  midway  between  extension  and 
flexion,  the  occipital  and  sincipital  ends  of  the  head,  marked  o  and  F  respect- 
ively (Fig.  249),  will  rest  against  the  uterine  walls,  while  the  force  A  is  applied 
at  the  occipito-atlantoid  articulation.     Since  the  force  is  applied  nearer  to  the 


THE   MECHANISM    OF  LABOR. 


4S3 


occipital  end  of  the  head,  it  is  evident  that  a  greater  amount  of  impulse  will 
be  communicated  to  the  occiput;  and  since  the  resistances  are  of  necessity 
equal,  the  occiput  will  tend  to  advance  more  rapidly ;  but  advauce  of  the 
occiput  with  relative  delay  of  the  sinciput  is,  in  effect,  flexion.  The  head,  in 
fact,  becomes  a  lever  of  the  third  class,  in  which  the  pressure  of  the  resist- 
ances applied  to  the  longer  end  is  more  effective  in  delaying  progress  than  the 
equal  pressure  applied  to  the  shorter  end  of  the  lever. 

It  is  further  to  be  noticed  that  as  flexion  progresses  the  relation  between 
the  lengths  of  these  arms  is  so  altered  as  to  make  them  progressively  more 
unequal,  so  that,  as  the  head  flexes,  the  point  at  which  the  pressure  of  the 
resistance  is  applied  to  the  occipital  end  of  the  head  becomes  progressively 
nearer  to  the  vertebral  articulation. 

General  Intro-uterine  Fluid-pressure. — If  Figure  250  represents  the  situ- 
ation of  the  child  at  the  end  of  the  first  stage,  we  see  that  the  forces  A  and  B 
are   applied    directly   and   with   equal  c 

force  to  the  ends  of  the  head  ;  but  it  is 
evident  that  the  pressure  (C)  exerted 
upon  the  breech  of  the  infant  will  be 
transmitted  to  the  head  more  readily 
by  the  vertebral  column  than  by  the 
soft  tissues  of  the  trunk,  and  that  a 
large  portion  of  this  force  (C)  must 
therefore  be  concentrated  on  the  con- 
dyles. So  far  as  this  force  (C)  is  con- 
cerned, the  argument  used  in  explain- 
ing the  production  of  flexion  by  the 
influence  of  gravity  applies,  then,  with 
equal  force  to  this  condition. 

Direct  Contact  between  the  Breech 
and  the  Fundus. — The  whole  effect  of 
a  direct  pressure  upon  the  breech  by  the 
fundus  will  be  applied  to  the  condyles 
of  the  occiput,  and,  the  resistances  upon 
the  occiput  and  sinciput  being  of  neces- 
sity equal,  while  the  opposing  forces 
are  concentrated  at  a  point  much  nearer 
the  occiput,  it  is  evident  that  the  occipital  end  of  the  head  will  tend  to 
advauce  more  rapidly  than  the  frontal  end ;  but  advance  of  the  occiput  with 
relative  or  absolute  delay  of  the  sinciput  of  course  results  in  flexion. 

Irregular  Shape  of  the  Fetal  Skull. — The  occurrence  of  flexion  is  like- 
wise aided  by  the  second  factor  referred  to  above,  the  irregular  shape  of  the 
skull.  As  will  be  seen  by  analysis  of  the  opposing  forces  exerted  at  R  and  R' 
(Fig.  251),  if  the  effect  of  the  equal  resistances  at  R  and  R'  be  represented  by  the 
length  of  the  equal  lines  S  and  S'  drawn  perpendicular  to  the  surface  of  the 
skull  at  these  points  (the  direction  in  which  these  resistances  must,  according 


Fig.  250.— Diagram  illustrating  the  application 
of  a  preponderance  of  the  intra-uterine  fluid- 
pressure  to  the  occipital  end  of  the  head.  It  is 
evident  from  the  condition  of  the  head  lever  (see 
Fig.  249)  that  the  sinciput  is  exposed  to  the  force 
B,  plus  a  small  proportion  of  the  force  C,  while 
the  occiput  receives  the  force  A,  plus  the  greater 
part  of  the  force  C. 


484 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


to  well-known  mechanical  laws,  be  exerted),  the  construction  of  the  parallel- 
ogram of  forces  shows  that  the  line  T  (whose  length  represents  the  portion 
of  the  resistance  R  which  is  exerted  in  direct  opposition  to  descent)  is  much 
greater  than  that  of  the  line  T'  (which  represents  the  efficient  proportion 
of  the  resistance  -R').  From  this  it  is  evident  that  the  occipital  end  of  the 
head  is  exposed  not  only  to  greater  force  from  above,  but  also  to  less  resistance 
from  below,  while  the  sincipital  end  is  opposed  by  greater  resistance  and 
receives  a  less  amount  of  propulsive  power — conditions  which  can  only  result 
in  a  more  rapid  advance  of  the  occiput. 

As  soon  as  partial  flexion  has  been  accomplished  a  second  effect  of  the 
irregular  shape  of  the  head  comes  into  play,  and  there  must  be  accorded  such 
importance  as  is  due   to   it.     Figure   252  represents  a  partially-flexed  head 


Fig.  251.— Diagram  illustrating  the  influence  of  Fig.  252. —Diagram  illustrating  the  second- 

the  irregular  shape  of  the  skull  in  producing  flexion,  ary  effect  of  the  irregular  shape  of  the  head  in 

by  the  construction  of  the  parallelogram  of  forces.  promoting   flexion   after   partial    flexion   has 

It  is  seen  that  the  force  which  dilates  the  sinciput,  once  been  produced, 

represented  by  the  line  T,  is  greater  than  the  force 
which  dilates  the  occiput,  represented  by  the  line  T, 
which  represents  the  sinciput. 

engaged  in  the  elastic  canal  formed  by  the  lower  uterine  segment  and  the 
vagina.*  The  forces  A  and  B,  due  to  the  constriction  of  the  elastic  canal  in 
which  the  head  lies,  and  acting  necessarily  at  right  angles  to  the  surface  of 
contact,  will  then  form  a  pair  of  equal  but  not  opposite  forces — in  mechanical 
language  "a  couple" — the  effect  of  which  is  to  rotate  the  head  upon  a  trans- 
verse axis  at  C,  thus  increasing  its  flexion. 

It  will  be  noticed  that  all  these  causes  of  flexion  f  are  dependent  for  their 
existence  on  the  presence  of  resistances  acting  in  opposition  to  the  vis-a-tergo 
which  urges  the  head  downward,  and  it  necessarily  follows  from  this  fact  that 
flexion  occurs  most  rapidly  and  becomes  most  marked  when  the  resistances 
are  best  developed — a  theoretical  consideration  which  is  in  thorough  accord 
with  the  observed  fact  that  there  is  often  a  temporary  loss  of  flexion  in  the 
excavation,  where  the  space  is  the  greatest;  that  is,  that  flexion  is  generally 
better  marked  while  the  head  is  experiencing  the  well-developed  resistances  of 

*  The  fact  that  the  vaginal  walls  possess  at  the  end  of  pregnancy  intrinsic  muscles  of  con- 
siderable development,  though  too  often  wholly  neglected  in  the  consideration  of  the  mechan- 
ism of  labor,  is,  notwithstanding,  an  element  in  the  production  of  flexion  that  must  not  be 
forgotten. 

f  Except  the  last  and  least  important. 


THE  MECHANISM   OF  LABOR.  485 

the  superior  strait  than  in  the  excavation,  where  the  resistances  are  less.  So, 
too,  flexion  again  increases  when  the  head  reaches  the  inferior  strait.  Flexion 
is,  in  fact,  normally  more  marked  in  this  part  of  the  pelvis  than  in  any 
other ;  but  here  another  factor  comes  into  play. 

We  have  previously  seen  flexiou  produced  by  the  action  of  the  propelling 
forces  against  resistances  which  were  exerted  with  approximately  equal  force 
on  both  the  occiput  and  the  sinciput ;  but  when  the  head  reaches  the  inferior 
strait  its  occipital  end  rapidly  frees  itself  from  the  pressure  of  the  bones,  and 
is  opposed  only  by  the  resistances  of  the  soft  parts  of  the  pelvic  floor,  while 
the  sinciput  is  still  exposed  to  the  firm  resistance  of  the  bony  sacrum.  It  is 
evident  that  when  the  greater  pressure  is  exerted  on  the  longer  arm  of  the 
lever  extreme  flexion  is  a  necessary  result.  The  mechanical  explanation  is 
thus  in  complete  agreement  with  the  clinical  fact  that  the  deeper  is  the  engage- 
ment of  the  head,  the  more  marked  is  the  tendency  to  flexion  and  the  greater 
is  the  certainty  of  its  accomplishment- 
Rotation. — The  movements  of  descent  and  flexion  make  up  the  whole 
mechanism  of  the  earlier  part  of  the  second  stage  of  labor ;  but  another  factor 
— rotation — is  necessary  to  its  completion. 

The  mechanism  of  rotation  is,  unfortunately,  extremely  difficult  of  com- 
prehension ;  and,  as  nothing  is  more  difficult  than  to  teach  mechanical  prob- 
lems involving  the  use  of  three  dimensions  without  the  aid  of  models,  the 
student  will  be  wise  if  he  supplements  the  words  and  figures  of  any  written 
description  by  a  constant  inspection  of  the  dried  pelvis  and  by  the  results  of  the 
intrapelvic  touch  in  actual  clinical  work.  A  complete  comprehension  of  the 
mechanism  of  rotation  is  seldom  acquired  in  any  other  way.  The  student 
must,  at  all  events,  grasp  the  fundamental  fact  that  it  does  occur,  and  must 
always  occur,  before  expulsion  can  take  place. 

The  head  enters  obliquely  because  the  oblique  diameters  are  the  largest  at 
the  superior  strait,  but  it  must  emerge  in  an  antero-posterior  position — that 
is,  with  the  sagittal  suture  opposed  to  the  antero-posterior  diameter  of  the 
outlet — because  the  antero-posterior  diameter  is  the  largest  at  the  outlet.  The 
movement  by  which  the  oblique  position  at  the  brim  is  converted  into  an 
antero-posterior  position  at  the  outlet  is  known  obstetrically  as  rotation. 

To  understand  the  mechanism  of  rotation  it  is  necessary  to  remember,  first, 
that  with  good  flexion  (without  which  rotation  does  not  occur)  the  occipital 
end  of  the  head  is  on  a  lower  level  than  the  sincipital ;  that  is,  the  occiput 
receives  the  pressure  of  the  lower  portion  of  the  anterior  part  of  one  lateral 
wall,  while  the  sinciput  receives  the  pressure  of  the  iqiper  portion  of  rhe  pos- 
terior part  of  the  other  lateral  wall.  Secondly,  it  is  necessary  to  remember 
accurately  the  shape,  depth,  and  direction  of  the  spiral  grooves  described  on 
page  446  (Fig.  221).  Thirdly,  it  must  not  be  forgotten  that  whenever  oue 
end  of  the  head  executes  a  movement  of  rotation,  its  other  end  must,  of  course, 
move  simultaneously  in  the  opposite  direction.  As  the  head  enters,  O.  L.  A., 
in  the  usual  position  of  moderate  flexion  at  the  brim,  the  occiput  is  necessarilv 
in  contact  with  the  upper  part  of  the  anterior  groove  upon  the  left  side  of  the 


486 


AMERICAN    TEXT-BOOK    OF    OBSTETBICS. 


pelvis ;    though  the  groove  is  here  shallow,  the    occiput  is  unable  to  move 
away  from  it,  because  the  bregmatic  region  lies  at  this  time  in  the  deep  sacro- 


Cervix  dilated,  head  on 
posterior  vaginal  wall. 


Pelvic  floor,  with  rectun 


Fig.  253.— A  vertical  transverse  section  of  the  pelvis  (one-third  natural  size).  Position  of  the  head 
In  the  inferior  strait  after  complete  rotation.  The  tuberosities  of  the  ischia  prevent  any  further  rotary 
movement,  while  further  descent  is  opposed  only  by  the  soft  parts. 

iliac  notch   on   the  right  side.     As  descent   goes  on  the  occiput  enters  the 
anterior  groove  more  fully — that  is,  it  reaches  the  point  at  which  the  groove 


Fig.  254.— Forward  motion  of  the  head  during  the  stage  of  expulsion  under  the  influence  of  the  forward 
thrust  of  the  sacrum  and  the  pelvic  floor  (one-sixth  natural  size). 

is  too  deep  to  permit  an  easy  escape  of  the  occiput  from  its  guidance — and  by 
the  time  the  occiput  approaches  the  point  where  the  groove  turns  forward,  and 


THE   MECHANISM    OF  LABOR. 


487 


where  it  must  itself  turn  forward  to  avoid  the  pressure  of  the  projecting  iliac 
spiue,  the  suboccipito-frontal  diameter  is  in  the  brim  and  the  sinciput  is  in  the 
sacro-iliac  notch.  With  the  next  movement  of  descent  the  sinciput  slips  below 
the  promontory  and  is  in  contact  with  the  upper  and  shallow  part  of  the  pos- 
terior groove  on  the  right  side.  The  occipitofrontal  diameter  now  occupies 
the  extremely  large  oblique  diameter  of  the  excavation,  and  the  posterior  edge 
of  the  groove  in  which  the  sinciput  lies  is  here  so  ill  marked  that,  with  the  great 
space  aiforded  by  the  oblique  diameter  of  the  excavation,  it  would  be  an 
extremely  easy  matter  for  the  sinciput  to  slip  backward  into  the  hollow  of  the 
sacrum  if  any  force  tending  in  this  direction  were  applied.  This  force  is,  in 
fact,  applied  as  a  result  of  the  tendency  of  the  occiput  to  turn  forward  along 
the  course  of  the  anterior  groove  of  the  left  side,*  under  the  impulse  furnished 
by  the  pressure  of  the  projecting  iliac  spine  against  the  posterior  surface  of  the 
occipital  end  of  the  head.  But  when  the  sinciput  has  once  slipped  backward 
in  this  way  into  the  hollow  of  the  sacrum,  there  is  nothing  left  to  prevent  the 
occiput  from  turning  still  farther  forward,  until,  as  it  reaches  the  median 
line,  it  receives  the  thrust  of  the  other  side  of  the  pelvis,  and  is  steadied  in  its 


(^ 


Fig.  255.— Head  during  distention  of  the  pelvic  floor  after  rotation,  with  beginning  extension  (Smellie). 


median  position  by  its  reception  of  equal  pressures  on   each  side  from   the 

descending  rami  of  the  pubes  and  the  tuberosities  of  the  ischium. 

Expulsion. — The  parietal  bosses  now  lie  in  contact  with  the  tuberosities  of 

the  ischium.     The  narrow  bitemporal  diameter  corresponds  with  the  narrow 

transverse  diameter  of  the  pelvis  between  the  iliac  spines.     The  sinciput  is 

*  It  will  be  remembered  that  when  the  occiput  turns  forward  the  sinciput  must  of  necessity 
turn  backward. 


488 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


still  in  contact  with  the  lower  portion  of  the  sacrum,  and  the  occiput,  though 
steadied  on  both  sides  by  the  bones,  finds  its  descent  opposed  only  by  the  yield- 
ing tissues  of  the  vaginal  outlet  (Fig.  253).  Under  these  circumstances  (p.  482) 
the  propelling  force  from  above  concentrates  itself  upon  the  occiput  until  the 
perineum  is  fully  distended.  The  occipital  end  of  the  head  is  then  freed  from 
the  resistances,  while  the  whole  bregmatic  region  and  the  sinciput  form  a  rigid 
slanting  surface  which  is  opposed  to  the  slanting  surface  furnished  by  the 
sacrum  and  the  perineal  tissues  (Fig.  254).  As  a  consequence  the  driving  force 
of  the  uterine  pressure  is  converted  by  the  shunt  of  these  shelving  surfaces 
into  a  forward  thrust,  under  the  influence  of  which  the  head,  as  a  whole,  moves 
forward  until  its  progress  is  arrested  by  contact  of  the  nape  of  the  neck  with 
the  anterior  pelvic  wall.  The  large  fontauelle  is  now  at  the  fourchette,  the 
whole  of  the  occipital  half  of  the  head  is  free  from  pressure,  while  the  fore- 
head is  still  exposed  to  the  driving  force  of  the  uterine  muscle  above  *  and  to  the 
forward  shuntof  the  posterior  pelvic  wall.  The  necessary  result  is  a  forward  mo- 
tion of  the  head  with  arrest  of  the  neck  ;  that  is,  the  head  extends,  the  bregma, 
the  forehead,  and  the  face  successively  pass  the  fourchette,  and  the  head  is 
expelled  by  extension  (Figs.  254  and  255).  It  is  then  a  convenient  mnemonic 
that  in  normal  labor  the  head  descends  in  flexion  and  is  expelled  by  extension. 
The  time  occupied  by  the  latter  stages  of  the  expulsion  of  the  head — that 
is,  the  time  between  the  first  ajapearance  of  the  hairless  forehead  and  the  com- 
pletion of  the  expulsion — is  usually  very  brief.  This  rapid  motion  of  descent 
is  usually  followed  by  a  period  of  inaction,  which  is  due  to  the  fact  that  the 
decrease  in  the  volume  of  the  uterine  contents  has  been  so  great  as  to  exhaust 
the  contractile  power  of  the  uterine  fibres,  and  to  render  progress  impossible 
until  after  the  occurrence  of  the  peculiar  phenomenon  known  as  retraction. 

Retraction  of  the  Uterus. — It  is  well  known  that  the  amount  of  shortening- 
possible  to  any  given  muscular  fibre  is  very  definitely  limited,  and  it  is  believed 

that  the  extreme  shortening  of  the  uter- 
ine muscle  as  a  whole  that  is  observed 
during  labor  is  rendered  possible  by  a 
process  of  rearrangement  of  the  rela- 
tions of  the  fibres  of  the  uterine  muscle 
to  one  another,  known  as  retraction. 
The  way  in  which  this  process  is  ef- 
fected is  not  definitely  and  scientifically 
known,  but  the  conception  generally  ac- 
cepted as  a  working  hypothesis  is  that 
the  cells  of  the  uterine  muscle  not  only 
shorten,  but  rearrange  themselves  upon 
one  another  in  some  such  way  as  that 
diagrammatically  represented  by  Figure 
256,  A  and  B.  When  retraction  has 
once  taken  place  it  is  usually  permanent,  and  the  distinction  between  contrac- 
tion and  retraction,  whatever  it  may  mean  pathologically,  is  therefore  clinically 

*  As  transmitted  to  it  b_v  the  fluid  pressure. 


Fig.  25C— Diagrams  representing  the  hypothet- 
ical relations  between  the  uterine  fibres  in  unre- 
tracted  and  retracted  uteri :  A,  arrangement  of  the 
uterine  fibres  in  the  unretracted  uterus;  B,  ar- 
rangement of  the  uterine  fibres  in  the  retracted 
uterus. 


THE   MECHANISM   OF  LABOR.  489 

one  which  it  is  important  to  understand  and  to  bear  in  mind.  In  the  descrip- 
tion of  the  mechanism  of  labor  it  is  necessary  to  remember  that  the  fact  of 
retraction  is  an  established  entity,  notwithstanding  the  unestablished  position 
of  the  hypothesis  upon  which  its  existence  rests. 

When,  after  the  expulsion  of  the  head,  retraction  of  the  uterine  fibres  has 
been  effected,  the  rhythmic  contractions  again  set  in  and  the  process  of  expul- 
sion of  the  body  begins. 

Expulsion  of  the  Body :  Rotation  of  the  Shoulders. — The  shoulders  having 
entered  the  pelvis  during  the  expulsion  of  the  head,  they  are  usually  born  with 
the  next  few  succeeding  pains.  The  head  having  entered  in  the  first  oblique 
diameter,  it  is  evident  that  the  shoulders,  which  normally  lie  at  right  angles  to 
the  antero-posterior  diameters  of  the  head,  will  normally  enter  the  pelvis  in 
the  second  oblique  diameter.  As  the  shoulders  are  driven  down  by  the  pains, 
the  anterior  shoulder  follows  the  curved  line  of  least  resistance,  previously 
travelled  by  the  occiput,  while  the  posterior  shoulder  follows  the  path  of  the 
sinciput.  The  anterior  shoulder  thus  rotates  to  the  arch,  and  the  transverse 
axis  of  the  shoulders  occupies  the  antero-posterior  diameter  of  the  outlet. 

Restitidion  of  the  Head. — The  head,  being  now  free  from  pressure,  tends  to 
retain  or  reassume  its  natural  relation  to  the  shoulders,  and  thus  as  they  assume 
an  antero-posterior  diameter  the  already  expelled,  head  undergoes  an  external 
rotation  by  which  the  occiput  is  carried  to  a  position  opposite  the  left,  and  the 
sinciput  to  one  opposite  the  right,  buttock  of  the  mother.  This  process  is 
known  as  the  external  rotation  or  restitution  of  the  head.  The  shoulders  are, 
however,  so  small  and  soft  as  compared  with  the  head  that  the  mechanism  of 
their  rotation  is  not  infrequently  faulty  or  irregular.  It  may,  moreover, 
happen  that  at  the  time  of  their  entrance  the  action  of  the  intrinsic  muscles 
of  the  child  may  have  so  turned  the  body  that  the  transverse  axis  of  the 
shoulders  lies  at  an  acute  angle  to  the  antero-posterior  axis  of  the  head.  The 
small  and  soft  shoulders  may  from  this  cause  enter  the  pelvis  in  the  transverse, 
or  even  in  approximately  the  first  oblique,  diameter.  The  shoulder  which 
should  normally  have  been  the  posterior  may  thus  become  the  anterior,  and  in 
this  way  lead  to  such  an  excessive  external  rotation  of  the  head  that  the  occiput 
swings  around  to  the  right  buttock  of  the  mother.  This  faulty  process  is  com- 
monly known  as  super-rotation. 

Exptdsion  of  the  Shoulders. — The  shoulders  being  retained  in  the 
antero-posterior  diameter  by  the  pressure  of  the  tuberosities,  the  posterior 
shoulder  receives  the  forward  shunt  of  the  pelvic  floor,  which,  together  with 
the  curvature  of  the  body  necessary  to  admit  of  the  passage  of  the  curved 
pelvis,  jams  the  anterior  shoulder  against  the  symphysis  pubis  in  such  a  way 
(Fig.  257)  that  the  posterior  shoulder  sweeps  forward  over  the  perineum  and  is 
the  first  to  reach  the  vulva.  As  the  body  is  urged  onward  the  perineum 
retracts,  the  anterior  shoulder  appears  from  beneath  the  arch,  the  shoulders 
emerge  from  the  vulva,  following  the  direction  of  the  curve  of  Cams  (Fig.  222), 
and  the  remainder  of  the  body  rapidly  follows  in  the  same  path.  During  the 
process  of  expulsion  the  arms  normally  remain  crossed  upon  the  chest  in  the 


490 


AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 


usual  attitude  of  the  fetus,  but  they  are  not  infrequently  held  back  by  the  fric- 
tion of  the  pelvic  wall,  and  are  thus  forced  into  a  position  of  partial  exten- 
sion in  which  the  forearms  lie  across  the  abdomen. 

The  mechanism  of  the  second  stage  in  O.  D.  A.  positions  differs  from  that 


Fig.  2o7.— Expulsion  of  the  shoulders. 

of  O.  L.  A.   only  in   the  substitution   of  the  word   right  for  the   word   left 
throughout  the  description. 

C.  Mechanism  and  Management  of  the  Third  Stage  of  Labor. 

Mechanism  of  the  Third  Stage  of  Labor. — After  the  expulsion  of  the 
child  the  uterus  shuts  down  upon  the  placenta,  and  there  is  usually  a  period 
of  from  five  to  ten  minutes  during  which  little  or  no  contraction  is  apparent, 
this  interval  being  again  occupied  by  the  process  of  retraction  of  the  uterine 
fibres.  The  first  active  contractions  of  the  uterus  after  the  expulsion  of  the 
child  necessarily  lessen  the  area  of  the  uterine  surface  over  which  the  placenta 
is  attached,  and  thus  in  part  or  jn  whole  separate  the  placenta  from  the  uterine 
wall ;  during  the  next  relaxation  blood  escapes  from  the  torn  sinuses  in  the 
placental  site,  and  the  mechanism  by  which  the  placenta  is  expelled  depends 
upon  the  escape  or  non-escape  of  this  blood  from  the  uterus. 

If  the  first  retraction  is  sufficient  completely  to  detach  the  placenta,  but 
does  not  succeed  in  expelling  it,  any  blood  which  may  be  effused  will  usually 
find  its  way  to  the  external  world  by  dissection  of  the  membranes  from  the 
uterine  wall ;  during  the  next  few  contractions  the  uterus  will  be  able  to  shut 
down  upon  the  placenta,  and  will  compel  it,  by  the  force  of  direct  contact,  to 
pass  through  the  os  edgewise  and  in  the  most  compact  possible  form — that  is, 
in  the  shape  shown  in  Figure  258,  in  which  the  thin  cake-like  placenta  is  seen 
to  have  been  folded  upon  itself  in  a  roughly  fusiform  shape. 

When,  however,  the  attachment  of  the  placenta  is  too  firm  to  permit  an 
immediate  separation,  or  when,  as  probably  more  frequently  happens,  the  con- 
traction of  the  fundus  is  more  energetic  than  that  of  the  lower  portion  of  the 
uterus,  so  that  only  the  upper  portion  of  the  placenta  is  detached,  the  relaxation 
following  each  contraction  will  be  accompanied  by  an  effusion  of  blood  which 
is  confined  behind  the  placenta.     The  upper  part  of  the  placenta  will  then  be 


THE  MECHANISM    OF  LABOR. 


491 


forced  downward,  and  as  the  detachment  proceeds  the  position  of  the  placenta 
will  be  so  far  altered  that  its  fetal  surface  presents  at  the  os,  the  uterine  cavity 
behind  it  being  occupied  by  a  mass  of  blood  (Fig.  259).     When  this  occurs, 


Fig.  258.— The  more  favorable  mechanism  of  expulsion  of  the  placenta  (Varnier). 

the  placenta  presents  in  so  much  more  bulky  a  form  that  it  is  usually  expelled 
so  slowly  and  with  so  much  difficulty  that  the  process  is  not  completed  until 
the  effused  mass  of  blood  attains  sufficient  size  to  redistend  the  uterus  slightly, 


Fig.  259.— The  less  favorable  of  the  common  methods  of  expulsion  of  the  placenta  (Varnier). 

and  thus  permit  of  the  occurrence  of  more  forcible  coutractions.  The  placenta 
is  then  expelled,  not  by  the  force  of  direct  contact,  but  by  an  iutra-uterine 
fluid-pressure  exerted  through  the  mass  of  effused  blood. 

This  second  form  of  the  mechanism  of  the  third  stage  of  labor,  though 
essentially  normal,  is  much  the  less  easy  and  favorable  for  the  patient;  although 
the  amount  of  blood  lost  is  not  usually  sufficient  to  effect  any  perceptible  altera- 
tion in  her  pulse. 

In  either  mechanism  the  elastic  and  collapsible  nature  of  the  membranes 
renders  them  less  likely  than  the  placenta  to  be  thoroughly  detached,  and  as 
the  latter  emerges  through  the  hole  in  the  membranes  that  corresponds  with 
the  os  they  are  necessarily  inverted,  and,  becoming  detached  by  the  traction 
due  to  the  advance  of  the  placenta,  follow  after  it  in  a  loose  mass. 


492  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

Management  of  the  Third  Stage  of  Labor.* — The  inquiry  naturally 
arises:  How  far  is  it  within  the  power  of  the  obstetrician  to  favor  or  to  compel 
the  occurrence  of  the  mechanism  first  described  ?  To  this  inquiry  it  may  be 
answered  that  the  maintenance  of  a  careful  watch  upon  the  uterus  by  constant 
touch  of  the  fundus  through  the  abdominal  wall,  aud  the  institution  of  rapid 
but  light  friction  with  the  fingers  upon  the  fundus  during  the  first  contraction, 
usually  so  far  increase  its  duration  and  force  as  often  to  effect  the  complete 
separation  of  the  placenta.  Moreover,  if  this  friction  is  persisted  in  through- 
out the  succeeding  period  of  relaxation,  it  will  usually  maintain  sufficient  con- 
traction to  prevent  any  considerable  effusion,  and  secure  separation  during  the 
first  or  the  immediately  succeeding  pains.  This  most  essential  portion  of  the 
method  of  Crede  should  therefore  uniformly  be  adopted. 

The  second  and  less  favorable  mechanism  is  probably  safer  for  the  patient 
than  any  manual  method  of  removal  of  the  placenta,  but  in  case  a  delay  in 
the  third  stage,  notwithstanding  the  adoption  of  Creole's  method  of  expulsion, 
should  require  the  introduction  of  the  hand,  a  digital  intra-uterine  exami- 
nation should  first  be  made,  and  if  the  placenta  is  found  to  present  in  the  way 
shown  in  Figure  259,  an  effort  should  be  made  to  reach  the  edge  of  the  pla- 
centa with  the  finger.  It  may  then  be  possible  to  draw  the  edge  of  the  after- 
birth into  the  os,  and  thus  permit  its  ready  expulsion  without  the  complete 
introduction  of  the  hand. 

D.  Mechanism  and  Management  of   the  Posterior  Positions  of  Vertex 
Presentations. 

Mechanism  of  Right-posterior  Positions. — In  the  right-posterior  posi- 
tions of  vertex  presentations  the  head  always  enters  the  pelvis  O.  D.  P. ;  it 
should  invariably  enter  the  inferior  strait  in  a  right-anterior  position ;  but 
the  process  by  which  this  rotation  is  accomplished  is,  unfortunately,  so  deli- 
cately balanced  that  it  is  always  liable  to  a  failure,  and  this,  if  it  occurs, 
necessarily  results  in  a  persistence  of  the  posterior  position,  which,  though  not 
incompatible  with  a  natural  delivery,  is  attended  by  greatly  increased  risks  to 
both  mother  and  child. 

We  have  to  consider,  then,  first,  the  entrance  of  the  head  into  the  pelvis  in 
posterior  positions;  secondly,  the  normal  mechanism  of  the  subsequent  delivery 
by  rotation;  and  thirdly,  the  (abnormal)  mechanism  of  the  delivery  of  a  persist- 
ently posterior  occiput. 

Labor  in  posterior  positions  is  usually  longer  and  more  difficult  than  in 
anterior  positions,  for  two  reasons  :  first,  because  the  entrance  of  the  head 
into  the  pelvis  is  more  difficult;  and  second,  because,  even  under  the  most 
favorable  circumstances,  labor  is  sure  to  be  lengthened  by  the  more  extended 
rotation  of  the  occiput  that  is  necessary  to  its  completion. 

The  difficult  entrance  of  the  head  at  the  brim  in  occipito-posterior  positions 
is  due  to  the  existence  of  two  factors,  one  of  which  is  physiological,  while  the 
other  is  mechauical.     The  physiological  factor  is  to  be  found  in  an   irregular 

*  For  the  management  of  the  first  and  second  stages  of  normal  labor,  see  page  -J  17. 


THE   MECIIAXISM    OF  LABOR. 


493 


and  imperfect  action  of  the  pains,  that  characterizes  the  first  stage  of  labor  in 
a  large  proportion  of  posterior  positions.  The  exact  cause  of  this  well-marked 
feature  of  such  cases  is  unknown.  Probably  it  is  a  reflex  phenomenon  due 
to  pressure,  from  the  mechanical  mal-adaptation  shortly  to  be  spoken  of;  but 
it  is  a  fact  that  a  long  first  stage,  which  is  due  to  irregular,  variable,  and 
ineffective  pains,  is  always  suggestive  of  a  posterior  position. 

The  mechanical  factor  is  due  to  the  irregular  shapes  of  the  fetal  head  and 
the  pelvic  brim.  If  parallel  diameters  are  drawn  across  the  pelvic  brim  (Fig. 
'260).  the  one  (a)  from  the  i-ight  side  of  the  sacral  promontory  to  the  right  ilio- 


Fig.  260.— Adaptation  between  the  fetal  head  and  the  brim  of  the  pelvis  in  anterior  positions  of  the 

occiput. 


pectineal  eminence,  and  the  other  (b)  from  the  left  sacro-iliac  notch  to  the 
pubes,  it  will  be  seen  that  when  the  head  enters  O.  L.  A.,  the  wide  biparietal 
diameter  of  the  head  corresponds  with  the  greater  space  afforded  by  B,  the 
longer  of  these  diameters ;  while  the  lesser  bitemporal  diameter  is  in  corre- 
spondence with  A,  the  shorter  of  these  parallel  diameters. 

The  entrance  of  the  head  is  therefore  mechanically  easy  in  anterior  posi- 
tions ;  but,  conversely,  when  the  head  enters  O.  D.  P.,  its  wide  biparietal 
diameter  is  opposed  to  the  narrow  oblique  space  between  the  promontory  and 
the  ilio-pectineal  eminence  of  the  right  side,  while  the  narrow  biparietal 
diameter  is  loosely  fitted  into  the  wide  space  afforded  by  the  anterior  portion 
of  the  pelvis  (Fig.  261).  Two  factors  of  difficulty  are  thus  produced  :  first, 
the  widest  portion  of  the  fetal  head  finds  itself  in  apposition  with  a  narrow 
portion  of  the  pelvis,  and  therefore  requires  a  powerful  driving  impulse  to 
force  it  through  the  brim  ;  second,  this  retarded  widest  portion  of  the  head 
is  situated  on  the  occipital  end  of  the  head  lever,  while  the  sincipital  end  is 
almost  free.  This  situation,  therefore,  always  tends  toward  a  too  rapid  descent 
of  the  sinciput — that  is,  toward  the  production  of  extension — but  the  degree 


494 


AMERICAN    TEXT-BOOK    OF   OBSTETRICS. 


of  extension  produced   varies  with  the  relative  sizes  of  the  pelvis  and  the 
head. 

If  the  disproportion  between  the  biparietal  diameter  of  the  head  aud  the 
portion  of  the  pelvis  in  which  it  finds  itself  (that  is,  A,  Fig.  261)  is  not 
extremely  great,  the  production  of  an  extension  sufficient  to  cause  a  light 
pressure  of  the  forehead  against  the  pubes  may  be  enough  to  equalize  the 


Fig.  261.— Adaptation  between  the  fetal  head  and  the  brim  of  the  pelvis  in  posterior  positions  of  the 

occiput. 


resistances  at  the  opposite  ends  of  the  cephalic  lever,  and  may  thus  permit  the 
greater  propulsive  force  applied  to  the  occiput  (see  page  483)  to  accomplish 
its  descent  while  the  sinciput  is,  still  above  the  brim.  The  head  in  this  case 
will  enter  the  excavation  in  a  fairly  well  flexed  condition. 

If  the  disproportion  between  the  occiput  and  the  posterior  portion  of  the 
pelvis  is  more  extreme,  the  process  of  extension  will  continue  until  the  occipito- 
frontal diameter  occupies  the  first  oblique  diameter  of  the  brim.  The  head 
may  then  pass  the  brim,  after  long  labor,  in  an  extended  position  ;*  it  may  be 
arrested  at  the  brim  by  becoming  a  brow  presentation,  or  it  may  exceptionally 
be  converted  into  a  face  presentation. 

Passage  of  the  Excavation. — After  its  escape  from  the  superior  strait  the 
head  occupies  the  first  oblique  diameter  of  the  excavation  O.  D.  P.,  aud  the 
accomplishment  or  non-accomplishment  of  the  remainder  of  the  labor  by  the 
normal  mechanism  of  rotation  depends  wholly  on  the  degree  of  flexion 
present. 

Rotation  in  Well-flexed  Right-posterior  Positions. — When  the  occiput  enters 
the  excavation — that  is,  passes  below  the  promontory — while  the  sinciput  is 
still  delayed  in  or  above  the  brim,  it  occupies  for  the  moment  so  roomy  a  posi- 

*  It  will  be  remembered  that  the  occipito-frontal  diameter  is  too  large  to  pass  even  the 
oblique  diameters  at  the  brim  with  ease. 


THE   MECHANISM    OF  LABOR. 


495 


tion  that  it  is  enabled  to  descend  rapidly  almost  to  the  floor  of  the  pelvis, 
while  the  sinciput,  delayed  by  the  pressure  of  the  anterior  pelvic  wall,  makes 
but  slight  progress.  The  occiput  then  lies  between  the  sacrum  and  the  right 
ischium,  in  the  hollow  made  by  the  recession  of  the  elastic  sacro-sciatic  lig- 
aments— that  is,  in  the  deeper  portion  of  the  posterior  groove  of  the  right 
side  of  the  pelvis — while  the  sinciput  is  pressed  against  the  smooth  and  uniform 
surface  of  the  upper  part  of  the  anterior  portion  of  the  lateral  wall  on  the 
left  side.  As  descent  goes  on  the  occiput  follows  the  posterior  groove  forward 
under  the  pressure  of  the  unyielding  bony  edge  of  the  sacrum,  which  presses 
against  its  posterior  surface ;  this  motion  is  unopposed  by  the  sinciput,  which 
in  thoroughly  well  flexed  heads  is  still  so  high  in  the  pelvis  that  it  is  free  to 
turn  backward  over  the  smooth  bony  surface  of  the  upper  portion  of  the 
lateral  wall  (portion  A,  Fig.  220,  a  and  B,  Fig.  221).  Rotation  thus  pro- 
gresses smoothly,  and  usually  rapidly,  until  the  occiput'  reaches  the  spot  at 
which  the  posterior  and  anterior  grooves  of  the  right  side  join,  and  thus  assumes 
an  anterior  position.  The  sinciput,  which  has  by  this  time  become  well  pos- 
terior, now  lies  in  the  upper  portion  of  the  posterior  groove  of  the  left  side. 
The  head  is  now  in  an  O.  D.  A.  position  in  the  lower  portion   of  the  pelvis, 


Fig.  262.— Diagram  illustrating  the  possible  reproduction  of  flexion  in  partly  extended  posterior  posi- 
tions of  the  occiput.  The  force  of  rotation  is  represented  by  the  arrow  a;  the  portion  of  that  force  which 
is  applicable  to  flexion,  by  the  line  b. 

and  the  remainder  of  the  mechanism,  including  restitution,  is  exactly  similar 
to  that  which  would  have  obtained  in  an  originally  O.  D.  A.  position  (see  pp. 
480-490). 

Mechanism  of  Rotation  when  the  Head  enters  Poorly  Flexed  in  Right-pos- 
terior Positions. — When  more  marked,  but  not  extreme,  extension  occurs  across 
the  brim  before  the  passage  of  the  occiput,  the  release  of  the  latter,  as  be- 
fore, permits  it  to  make  a  rapid  descent   until  it  is  arrested  by  contact  with 


496  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

the  pelvic  floor ;  but  at  the  time  when  the  occiput  begins  to  feel  the  forward 
impulse  of  the  deep  lower  portion  of  the  posterior  groove  of  the  right  pelvic 
wall  the  sinciput  is  not,  as  before,  in  contact  with  the  smooth  surface  of  por- 
tion a  of  the  left  lateral  wall,  but  has,  on  the  contrary,  already  entered  the 
upper  portion  of  the  anterior  groove  on  that  side.  Under  these  circumstances 
rotation  may  exceptionally  be  accomplished.  When  this  does  happen  the 
mechanism  is  as  follows :  As  the  occiput  is  urged  forward,  the  posterior  side 
of  the  sinciput  is  pressed  firmly  against  the  slightly  rising  edge  of  the  upper 
portion  of  the  anterior  groove,  and  under  favorable  circumstances  this  increased 
pressure  may  result  in  flexion  of  the  head  in  the  manner  illustrated  in  Figure 
262,  which  is  a  horizontal  section  of  the  pelvis  through  the  spot  where  the 
sinciput  impinges  against  the  lateral  wall.  The  rotation  force  due  to  the  for- 
ward motion  of  the  occiput  urges  the  sinciput  backward  in  the  direction  of 
the  force  represented  by  the  arrow  A.  If  upon  this  arrow  we  construct  the 
parallelogram  of  forces,  we  see  that  by  the  shunt  of  the  shelving  surfaces  of 
the  sinciput  and  the  pelvic  wall  there  is  produced  a  small  pressure  (b)  upon 
the  sinciput  that  tends  directly  to  flexion,  and  that  may,  under  favorable  cir- 
cumstances, actually  produce  flexion  to  a  degree  sufficient  to  permit  the  sinciput 
to  slip  by  on  to  the  smooth  surface  of  portion  A  (Fig.  220).  The  sinciput  is 
free  to  then  glide  back  into  the  posterior  groove  as  the  occiput  moves  forward, 
and  the  mechanism  of  rotation  described  above  goes  on  as  before. 

This  process,  however,  is  mechanically  so  extremely  difficult  that  it  can 
occur  only  under  the  most  favorable  conditions — that  is,  when  the  adaptation 
is  easy,  when  the  pains  are  powerful,  and,  most  important  of  all,  when  the 
loss  of  flexion  is  so  extremely  slight  that  but  a  slight  change  is  needed  to 
restore  it. 

Mechanism  of  Rotation  when  the.  Head  enters  Unflexed  in  Posterior  Posi- 
tions :  the  Mechanism  of  the  Passage  of  the  Excavation  in  Persistent  Right-pos- 
terior Positions. — When  the  head  passes  the  brim  so  far  extended  that  the 
sinciput  is  as  low,  or  nearly  as  low,  in  the  pelvis  as  the  occiput,  the  forehead 
reaches  the  deeper  portion  of  the  anterior  groove  at  about  the  same  time  that 
the  occiput  reaches  the  deeper  portion  of  the  posterior  groove.  Both  ends  of 
the  head  are  then  urged  to  rotate  forward  by  the  forward  trend  of  their  re- 
spective grooves ;  since  neither  one  can  rotate  forward  unless  the  other  turns 
back,  there  results  a  dead-lock  which  can  be  broken  only  by  the  intervention 
of  art — that  is,  by  a  manual  or  an  instrumental  flexion  of  the  head.  In  rare 
cases,  however,  this  dead-lock  may  be  avoided  by  the  occurrence  of  a 
second  and  abnormal  mechanism,  by  which  the  occiput  is  rotated  directly 
backward  into  the  hollow  of  the  sacrum.  This  rotation  can  occur  only  when 
the  adaptation  between  the  head  and  the  pelvis  is  exceptionally  easy,  when 
the  sacrum  is  exceptionally  hollow,  and  when  its  lateral  concavity  is  but 
little  marked.  The  occurrence  of  a  backward  rotation  is  then  due  to  the 
fact  that  the  posterior  edge  of  the  anterior  groove,  formed  by  the  ischiatic 
spine,  is  more  prominent  than  the  corresponding  portion  of  the  posterior 
groove,  formed  by  the  edge  of  the  sacrum.     If,  under  these  circumstances, 


THE   MECHANISM    OF  LABOR. 


49* 


the  occiput  ami  the  sinciput  are  at  equal  depths  iu  the  pelvis,  it  results  that 
the  sinciput  is  more  firmly  fixed  in  the  anterior  groove  than  is  the  occiput 
in  the  posterior ;  and  if  the  adaptation  is  exceptionally  easy  or  the  lower 
portion  of  the  sacrum  is  wanting  iu  prominence,  the  occiput  may  be  able  to 
escape  from  the  posterior  groove  and  turn  backward  over  the  sacrum  as  the 
sinciput  rotates  forward.  This  escape  of  the  occiput  into  the  hollow  of  the 
sacrum  usually  so  far  diminishes  the  pressure  on  the  occiput  as  to  permit  of  its 
rapid  advance,  while  the  descent  of  the  sinciput  is  still  delayed  by  the  normal 
resistances  of  the  anterior  wall  of  the  pelvis.  The  rapid  descent  of  the  occi- 
put as  compared  with  the  sinciput  thus  re-establishes  flexion,  with  the  head 
in  a  directly  occipito-posterior  position.  Expulsion  of  the  head  in  a  persist- 
ently posterior  position  by  the  natural  forces  or  by  the  aid  of  forceps  is  then 
possible,  though  the  conditions  are  much  less  favorable  than  when  the  occiput 
is  rotated  forward,  as  may  be  seen  by  reference  to  Figure  263.    On  comparing 


Fig.  263.— Expulsion  of  the  head  in  persistently  posterior  positions  of  the  occiput ;  mechanism  of  face 
to  pubes  delivery. 

Figure  263  with  Figure  254  it  will  be  seen  that  when  the  occiput  is  anterior 
the  curved  axis  of  the  child's  head  and  body  corresponds  with  the  curved  axis 
of  the  pelvis,  but  that  when  the  occiput  is  posterior  these  curves  are  reversed 
upon  each  other,  and  that  to  effect  the  delivery  iu  this  position  the  uterine 
forces  must  alter  the  shape  of  the  child  by  elongating  the  occiput,  by  com- 
pressing the  sinciput,  and  by  producing  an  exaggerated  flexion  uutil  the  normal 
curve  of  the  fetal  axis  is  reversed.  Although  the  fetal  head  is  surprisingly 
tolerant  of  the  excessive  compression  necessary  for  this  change  of  shape,  the 
process  always  results  in  the  stillbirth  of  a  large  proportion  of  the  children  ; 
while  the  prominence  of  the  occiput,  even  after  the  most  extreme  moulding, 
always  exposes  the  soft  tissues  of  the  pelvic  floor  to  a  degree  of  tension  that 
almost  invariably  results  in  deep  laceration  of  these  structures  during  the 
stage  of  expulsion.  The  expulsion  of  a  persistent  occiput  posterior,  more- 
over, always  requires,  in  addition  to  lax  adaptation,  the  presence   of  very 


498 


AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 


powerful  uterine  contractions  or  the  application  of  powerful  traction  by  the 
forceps ;  and  even  when  these  conditions  are  present  the  process  is  a  long 
one. 

The  head  remains  on  the  perineum  until  the  processes  of  the  change  in  its 
shaj^e  and  the  production  of  extreme  flexion  are  sufficiently  far  advanced  to  per- 
mit the  occiput  to  travel  downward  along  the  median  line  of  the  posterior  wall 
under  the  influence  of  the  pressure  from  above.  The  region  of  the  small  fonta- 
nelle  finally  appears  at  the  vulva,  and  the  perineum  retracts,  or,  more  com- 
monly, tears  across  the  occiput  to  the  base  of  the  neck.  The  occipital  end  of 
the  head  is  then  free  from  pressure,  while  the  sincipital  end  is  still  exposed  to 
the  driving  force  of  the  uterine  contractions.  The  excess  of  pressure  upon 
the  sincipital  end  of  the  head  then  causes  extension,  by  which  the  forehead, 
the  eyes,  the  nose,  and  the  chin  successively  appear  under  the  arch,  while  the 
occiput  swings  backward,  and  the  head  is  born  by  extension  (Fig.  263). 

Restitution. — During  the  expulsion  of  the  head  the  shoulders  enter  in  the 
second  oblique  diameter,  and  the  rotation  of  the  left  (the  anterior)  shoulder  to 


Tig.  264.— Occipito-posterior  position,  with  the  head  beginning  to  distend  the  pelvic  floor  (Smellie). 

the  arch  produces  an  external  restitution  to  the  right,  in  accordance  with  the 
general  law  that  external  rotation  or  restitution  restores  the  head  to  its  origi- 
nal position.  Abnormal  or  so-called  "  super-rotation"  is,  however,  of  especially 
common  occurrence  in  these  cases. 

Summary. — In  reviewing  the  mechanism  of  posterior  positions  it  is  at  once 
apparent  that  the  whole  key  to  the  situation  is  to  be  found  in  the  degree  of 
flexion  presented — that  the  better  the  flexion  the  more  certain  and  the  more 
rapid  is  the  execution  of  the  normal  and  most  favorable  mechanism.     It  is  an 


THE  MECHANISM   OF  LABOR.  499 

established  fact  in  practice  that  in  the  comparatively  few  cases  in  which  good 
flexion  is  established  at  the  start  and  maintained  to  the  end,  posterior  labor  is 
hardly  less  favorable  than  anterior ;  and  that  the  degree  of  difficulty  increases 
as  the  degree  and  persistence  of  flexion  decrease,  until  we  reach  the  fact  that 
when  flexion  is  lost  and  is  not  promptly  restored  by  art,  posterior  positions 
invariably  yield  long,  difficult,  and  exhausting  labors  for  the  mother,  and  a 
large  proportion  of  stillbirths  among  the  children.  It  may  safely  be  said  that 
there  is  no  variety  of  labor  in  which  easily-avoided  ill  results  are  so  commonly 
incurred  as  in  posterior  positions  of  the  vertex ;  and  there  is  certainly  no  sub- 
ject in  obstetrics  that  better  deserves  the  attention  of  the  student  than  the 
means  of  detecting  extension  and  of  preserving  or  re-establishing  flexion  in 
these  cases. 

Mechanism  of  Left-posterior  Positions. — Of  the  mechanism  of  O.  L.  P. 
positions  it  is  only  necessary  to  say  that  it  differs  from  that  of  O.  D.  P.  posi- 
tions simply  in  the  substitution  of  one  side  of  the  pelvis  for  the  other,  and  in 
the  fact  that  failure  of  rotation  is  more  common  in  left  positions. 

Management  of  Labor  in  Posterior  Positions  of  the  Vertex. — Prophy- 
laxis.— Since  posterior  labor  is  so  much  less  favorable  than  anterior,  it  is  evi- 
dent that  every  effort  should  be  made  to  prevent  the  occurrence  of  posterior 
positions,  or,  when  they  do  occur,  to  convert  them  into  anterior  positions 
before  the  occurrence  of  labor  or  during  its  early  stages.  We  are,  fortunately, 
able  to  effect  this  end  in  the  great  majority  of  cases,  provided  the  position  is 
diagnosticated  before  the  ruptui'e  of  the  membranes  or  the  engagement  of  the 
head.  For  this  reason,  if  for  no  other,  the  obstetrician  should  in  every  case 
endeavor  to  ascertain  the  position  of  the  fetus  by  making  an  abdominal  pal- 
pation some  days  before  the  advent  of  labor.  If  a  posterior  position  is  dis- 
covered at  this  time,  it  is  usually  possible  to'  rectify  it  by  postural  treatment 
of  the  patient. 

If  the  patient  is  placed  in  the  knee-chest  position,  the  anterior  wall  and 
the  fundus  are  the  lowest  portions  of  the  uterus.  So  long  as  the  patient 
remains  in  this  position  there  is  a  tendency  for  the  child  to  sag  away  from  the 
brim  under  the  influence  of  gravity ;  and  since  the  recession  of  the  head  from 
the  brim  leaves  the  child  free  to  turn  upon  its  own  axis,  while  the  presence  of 
the  spinal  column  makes  the  dorsal  side  the  heavier,  there  is  also  a  tendency 
toward  a  rotation  of  the  fetus  as  a  whole  until  its  dorsum  is  in  apposition  to 
the  anterior  wall  of  the  uterus. 

The  woman  should  in  such  cases  be  instructed  to  assume  the  knee-chest 
posture  several  times  daily  during  the  last  few  weeks  of  pregnancy,  to  remain 
as  long  in  this  position  as  is  possible  without  fatigue,  and,  on  relinquishing  it, 
to  recline  on  the  right  side  for  a  short  time  before  rising,  in  the  hope  that  as 
the  child's  head  again  settles  down  against  the  brim  it  may  become  fixed  in  an 
anterior  position. 

The  enlarged  abdomen  of  the  gravida  at  term  may  prevent  the  assumption 
of  the  true  geuu-pectoral  position  and  compel  her  to  adopt  the  knee-elbow  atti- 
tude ;  but  in  either  event  it  is  essential  that  the  abdomen  should  be  free  from 


500  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

pressure  against  either  the  bed  or  the  thighs  of  the  patient ;  that  is,  the  thighs 
should  be  vertical  (Fig.  265). 

The  postural  treatment  is  especially  powerful  when  instituted  before  any 
labor-pains  have  occurred.  If  this  treatment  is  conscientiously  carried  out  for 
several  davs,  the  physician  will  almost  surely  find  the  position  anterior  when 
summoned  to  the  patient  in  labor. 

Even  if  the  patient  is  not  seen  until  labor  is  present,  it  is  still  worth  while 
to  adopt  a  postural  treatment  so  long  as  the  membranes  are  unruptured  and 

the   head   is  unengaged.     The   patient 

^       ^  should  then  be  encouraged  to  maintain 

^j/\^  this   position  so   long  as   her  strength 

permits,  or  until  a  vaginal  examination 

B  without  alteration  of  her  attitude  dem- 

-~s>^~^  onstrates    the    fact    that    rotation    has 

occurred.     She  should   then  be  placed 

^j^  in  the   latero-proue   position  upon  the 

c=-^-  ^=a —  side  to  which  the  occiput  is  directed, 

Fig.  265-Correct  (A)  and  incorrect  (B  and  aQ(\  should  remain  ill  that  position 
C)  methods  of  assuming  the  genu-pectoral  posi-  .,     ,       ,         ,    .      „        ,  ■■    .        , 

tion  until  the  head  is  firmly  engaged  m  the 

new  position.  Should  the  head,  after 
once  becoming  anterior,  show  any  tendency  to  revert  to  the  posterior  position, 
it  mav  even  be  wise  to  rupture  the  membranes  in  order  to  prevent  any  such 
reversion. 

Should  the  postural  treatment  fail,  no  special  treatment  is  necessary  until 
after  the  rupture  of  the  membranes  has  occurred  ;  but  both  before  and  after 
rupture  frequent  examinations  are  to  be  advised,  in  order  to  detect  early  any 
tendency  to  the  production  of  marked  extension. 

Passage  of  the  Superior  Stf-'ait. — In  the  majority  of  cases  the  head  in  pos- 
terior positions  passes  the  superior  strait  by  the  natural  efforts  only  after  some 
delay,  and  often  only  after  the  occurrence  of  some  extension  and  of  considerable 
moulding  of  the  head. 

The  attitude  of  the  phvsician  should  be  determined  by  the  degree  of  exten- 
sion presented.  When  the  extension  is  not  extreme,  he  should  not  be  alarmed 
by  a  failure  of  progress,  but  should  avoid  interference,  and  expect  the  best 
results  so  long  as  the  condition  of  both  patients  remains  good. 

When  extension  becomes  so  extreme  that  the  eyebrows  are  below  the 
brim  of  the  pelvis,  there  is  but  little  prospect  that  the  head  will  pass  the 
superior  strait  by  the  natural  efforts,  aud  unless  active  progress  is  present  it 
is  wise,  after  a  single  hour  has  passed  without  alteration  of  the  condition,  to 
abandon  the  expectant  method  of  treatment  and  resort  at  once  to  the  operative 
treatment  of  a  high  arrest  of  the  posterior  occiput. 

Operative  treatment  at  the  superior  strait  subdivides  itself  into  the  operative 
re-establishmeut  of  flexion  and  the  delivery  through  the  superior  strait  of  the 
flexed  but  arrested  head. 

Operative  Flexion. — If,  at  the  time  when  operative  flexion  becomes  neces- 


THE    MECHANISM    OF  LABOR.  501 

sary,  the  membranes  are  still  intact,  it  may  occasionally  be  possible  to  raise  the 
forehead  by  making'  pressure  upon  it  with  two  ringers  placed  within  the  cervix, 
the  woman  being  in  the  laterally  recumbent  or  knee-chest  position,  in  order 
to  afford  the  assistance  of  gravity  to  the  efforts  of  the  accoucheur.  Since  it  is 
impossible,  however,  to  obtain  complete  flexion  of  the  head  in  this  way,  and 
since  the  extension  is  almost  certain  to  recur  if  no  further  change  is  made, 
it  is  essential  that  the  head  as  a  whole  should  be  freed  from  the  brim  by  pres- 
sure upon  the  vertex,  after  flexion  has  been  secured,  in  the  hope  that  on  its  en- 
trance it  may  be  better  situated,  and  may  thus  be  able  to  maintain  its  flexion. 

Should  extension  again  recur,  it  is  best  to  etherize  the  patient,  introduce 
the  hand  into  the  vagina,  and  dilate  the  os  manually  to  a  degree  sufficient  to 
permit  the  passage  of  the  half  hand  within  the  uterus.  Should  the  membranes 
be  ruptured  at  the  time  when  interference  is  decided  upon,  this  must  usually 
be  the  first  maneuvre.  When  sufficient  dilatation  has  been  attained,  the  half 
hand  should  be  passed  within  the  os  until  the  fingers  cover  the  forehead, 
which  should  then  be  pressed  gently  upward  until  complete  flexion  has  been 
secured  and  the  head  has  been  freed  from  the  brim.  The  hand  should  then 
be  withdrawn,  the  fingers  placed  as  high  upon  the  forehead  as  possible  in 
order  to  maintain  flexion,  and  the  head  forced  into  the  brim  by  external  pres- 
sure. The  ether  should  be  removed,  and  the  fingers  should  maintain  pressure 
upon  the  sincipital  portion  of  the  head  until  a  firm  engagement  in  a  flexed 
position  has  been  effected  by  the  efforts  of  the  uterus.  Should  extension  be- 
come re-established,  an  operative  delivery  of  the  head  is  necessary. 

Operative  Delivery  of  a  High  Arrest  of  the  Posterior  Occiput. — If  extension 
is  present,  flexion  should  be  established  by  the  introduction  of  the  half  hand. 
Three  methods  of  delivery  are  then  possible  :  The  child  ma}'  at  once  be  turned, 
the  head  may  be  rotated  manually  and  forceps  applied  to  the  anterior  occiput, 
or  forceps  may  be  used  while  the  occiput  is  still  posterior. 

The  latter  method  is  to  be  recommended  only  when  the  other  methods  are, 
for  one  reason  or  another,  contra-indicated  or  impossible,  and  the  choice  ordi- 
narily rests  between  the  procedures  of  a  manual  rotation  of  the  occiput  to  the 
front  with  a  subsequent  application  of  the  forceps,  and  version. 

Manual  rotation  and  the  application  of  forceps  is  a  difficult,  and  version  in 
normal  pelves  is  an  easy,  operation.  The  head  after  manual  rotation  not 
infrequently  returns  to  its  original  position  during  the  manipulations  incident 
to  the  application  of  the  blades,  and  in  any  event  it  is  necessary  to  applv  the 
forceps  to  the  head  when  freely  movable  above  the  brim,  which  operation  is 
always  difficult.  The  writer  believes,  however,  that  after  the  forceps  has 
successfully  been  applied  to  the  head  in  an  anterior  position,  an  extraction  with 
it  is  less  dangerous  to  the  soft  parts  of  the  mother  than  is  the  extraction  of  an 
after-coming  head  ;  the  forceps  operation  should  therefore,  in  his  opinion,  be 
chosen  by  those  who  are  thoroughly  skilful  in  the  use  of  the  instrument,  but 
the  primary  performance  of  version  should  be  elected  by  operators  of  small 
experience. 

Should  manual  rotation  and  the  use  of  forceps  be  decided  upon,  the  whole 


502  AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 

hand  should  be  passed  into  the  uterus  and  the  head  be  raised  gently  until  the 
whole  surface  of  the  hand  can  be  applied  to  the  forehead,  the  fingers  lying 
over  the  face  of  the  child  ;  whereupon  the  hand  and  the  forearm  of  the  operator 
should  be  rotated  with  the  head  until  the  occiput  is  well  anterior  to,  and  even,  if 
possible,  to  the  left  of,  the  median  line.  During  the  introduction  of  the  hand 
careful  counter-pressure  must  be  made  at  the  fundus  by  an  assistant  or  by  the 
other  hand  of  the  operator,  and  during  the  rotation  the  external  hand  must  be 
used  to  promote  the  rotation  of  the  trunk.  The  rotation  should  always  be  slow 
and  be  procured  with  the  utmost  gentleness.  Unless  the  rotation  of  the  trunk 
accompanies  that  of  the  body,  the  head  will  return  to  its  original  position  as 
soon  as  it  is  free  from  pressure.  In  difficult  cases  it  may  occasionally  be  per- 
missible to  apply  the  internal  fingers  to  the  shoulder  of  the  child  to  promote 
this  rotation.  The  whole  mauenvre  is  frequently  so  difficult  that,  unless  the 
waters  have  been  but  recently  evacuated,  it  should  not  be  attempted  until  a  fair 
experience  in  version  has  furnished  the  operator  with  some  adroitness  in  intra- 
uterine manipulations. 

After  rotation  has  been  effected  the  head  should  be  urged  into  the  brim  by 
counter-pressure  upon  the  fundus,  and  it  should  be  maintained  in  position  by 
gentle  abdominal  pressure  ujdou  the  head  itself,  from  the  hands  of  an  assistant, 
while  the  forceps  application  is  made.  The  forceps  should  be  applied,  if  pos- 
sible, to  the  sides  of  the  head,  and,  as  in  all  high  operations,  the  use  of  an 
axis-traction  instrument  is  to  be  recommended. 

If  version  is  decided  upon,  the  head  should  be  flexed  before  it  is  raised,  as 
this  always  requires  less  force  than  an  attempt  to  raise  the  extended   head. 

If  version  is  absolutely  contra-indicated  and  manual  rotation  fails,  an  attempt 
should  be  made  to  bring  the  head  through  the  superior  strait  by  the  application 
of  forceps  without  alteration  of  the  position  ;  but  as  a  preliminary  even  to  this 
operation  an  extended  head  should  gently  be  flexed. 

In  the  use  of  forceps  while  the  occiput  is  still  posterior,  it  is  inadvisable  to 
make  any  attempt  to  apply  the  blades  to  the  sides  of  the  head,  as  the  position 
of  the  parietal  bosses  in  the  narrow  space  between  the  ilio-pectineal  eminence 
and  the  promoutory  makes  it  extremely  difficult  to  adjust  the  forceps  to  the 
ends  of  the  biparietal  diameter.  Even  when  it  is  so  adjusted  a  very  slight 
forward  inclination  of  the  line  of  traction  may  cause  the  forceps  to  slip  forward 
along  the  head  to  the  temporal  region.  In  this  position  the  forceps  is  extremely 
likely  to  slip  from  the  head  altogether ;  even  if  the  forceps  holds  its  position, 
the  sole  and  necessary  result  of  traction  is  a  reproduction  of  the  extension,  which, 
of  course,  results  in  an  arrest,  or  at  least  requires  the  use  of  increased  and 
unnecessary  force.  The  blades  should  therefore  be  applied  to  the  sides  of  the' 
pelvis,  where  they  will  take  an  oblique  grip  upon  the  head.  This  application 
is  always  very  difficult,  and  the  operation  too  frequently  results  in  a  fracture 
of  the  skull  or  in  the  birth  of  a  stillborn  child  from  cranial  compression.  As 
soon  as  the  head  has  passed  the  brim  the  forceps  should  be  removed,  and  if 
necessary  reapplied  in  the  manner  shortly  to  be  recommended  for  the  oper- 
ative treatment  of  the  low  head  in  posterior  positions. 


THE   MECHANISM    OF  LABOR.  503 

Management  of  the  Passage  of  the  Excavation  in  Posterior  Positions. — 
Flexion. — As  was  said  in  the  discussion  of  the  mechanism  of  posterior  posi- 
tions, the  maintenance  of  complete  flexion  is  the  first  and  most  essential  con- 
dition of  the  progress  of  the  head  through  the  excavation.  It  follows  that  the 
maintenance  of  flexion  when  possible,  and  its  re-establishment  when  it  has  been 
lost,  must  demand  throughout  the  case  the  most  careful  attention  from  the 
obstetrician. 

When  the  adaptation  is  easy  and  good  flexion  is  present  from  the  start, 
descent  and  rotation  to  an  anterior  position  are  sometimes  so  quickly  performed 
that  no  assistance  is  needed ;  but  in  a  large  proportion  of  cases  the  head  enters 
the  excavation  in  a  condition  of  partial  extension,  and  in  such  cases  an  early 
adoption  of  certain  very  simple  measures  frequently  makes  the  difference 
between  difficult  and  easy  labors.  The  various  expedients  which  may  be  used 
to  promote  or  to  re-establish  flexion  form,  then,  the  first  and  most  important 
division  of  the  treatment  of  the  low  head  in  posterior  positions;  but,  since  it 
not  infrequently  happens  that  even  a  well-flexed  head  fails  to  rotate  from  over- 
tightness  of  adaptation,  from  relative  inefficiency  of  the  pains,  or  from  minor 
variations  in  the  shape  of  the  head  and  the  pelvis,  it  is  necessary  to  add  thereto 
a  second  division,  which  consists  of  the  expedients  that  may  be  employed  to 
favor  or  to  produce  rotation  during  extraction,  whenever,  from  any  cause,  a 
well-flexed  head  is  arrested  in  a  posterior  position  in  the  excavation. 

Maintenance  of  Flexion. — Unless  progress  goes  on  with  unusual  rapidity, 
the  maintenance  of  flexion  by  counter-pressure  should  be  undertaken  as  soon 
as  the  head  has  entered  the  excavation  and  the  forehead  is  within  easy  reach. 
As  soon  as  the  degree  of  descent  permits,  the  fingers  should  be  placed  against 
the  frontal  bones  as  far  forward  of  the  large  fontanelle  as  the  pelvic  space  allows, 
and  any  further  descent  of  the  sinciput  should  be  retarded  by  a  maintenance  of 
pressure  against  the  forehead  throughout  the  whole  of  each  pain  until  the  occur- 
rence of  rotation  carries  the  frontal  bones  backward  and  out  of  the  reach  of  the 
fingers.  In  this  process  a  simple  retardation  of  the  descent  of  the  sinciput  is 
all  that  is  to  be  aimed  at  or  desired,  since  flexion  is  supposed  to  be  already 
present,  and  its  maintenance  is  all  that  is  needed.  This  maintenance  of  flex- 
ion, which  is  usually  easy,  is  always  a  very  much  more  simple  matter  than  is 
an  attempt  to  raise  the  forehead  by  pressure  after  extension  has  once  occurred. 
If  this  precaution  is  carefully  observed  from  the  start,  loss  of  flexion  is 
extremely  rare,  and  a  recourse  to  the  more  heroic  methods  required  for  its 
re-establishment  may  usually  be  avoided. 

Re-establishment  of  Flexion. — When  extension  occurs,  it  must  be  reduced 
before  any  further  progress  is  possible.  Flexion  may  be  re-established  either 
by  pushing  the  sinciput  up,  by  drawing  the  occiput  down,  or  by  a  combination 
of  both  methods.  The  forehead  may  occasionally  be  made  to  recede  by  pres- 
sure upon  the  frontal  bones  with  the  fingers  ;  it  should  then  be  held  in  position 
until  the  uterine  efforts  have  effected  complete  flexion  by  descent  of  the  occiput, 
and  until  rotation  has  occurred.  This  method,  the  simplest  and  safest,  is,  how- 
ever, possible  only  in  very  easy  cases. 


504 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


It  is  occasionally  possible  to  reinforce  this  method  by  hooking  the  fingers 
of  the  hand  around  the  occiput,  and  thus  drawing  down  upon  the  occiput  with 
one  hand  while  the  sinciput  is  pressed  up  by  the  other  hand.  This  method  is 
possible  only  when  the  extended  head  is  very  low  and  the  soft  tissues  of  the 
outlet  are  very  lax  ;  in  the  majority  of  cases  in  which  extension  has  fully  been 
established  it  is  necessary  to  resort  to  instrumental  methods. 

The  vectis  (Fig.  266),  which  was  the  precursor  of  the  forceps,  was  originally 
used  to  promote  the  descent  of  the  head  by  the  application  of  leverage  motions 
to  the  sides  of  the  head  in  alternation.     The  vectis  is 
never  used  to-day  except  for  the  reduction  of  exten- 
sion, and,  in   the    opinion   of  the  writer,  cannot  be 
recommended  even  for  this  purpose,  since,  in  the  first 
place,  its  efficiency  depends   on   its  possession  of  an 
exaggerated  cephalic  curve  which  renders  its  intro- 
duction difficult,  and,  in  the  second  place,  it  can  rarely 
be  prevented    from    slipping,    without  the  use  of  a 
degree  of  force  which  exposes  both  the  vagina  of  the 
mother  and  the  scalp  of  the  child    to  serious  risks 
of    laceration.      If    employed,    the    vectis    is   passed 
around    the  occiput  and   is   used   to  draw   it  down, 
while  the  delay  of  the  sinciput  is  entrusted   to  the 
friction  of  the  pelvic  walls  or  to  counter-pressure  by 
fig.  266.-The  vectis.         the  fingers.     For  this  purpose  the  hand  of  an  assist- 
ant must    be   utilized,  since  the  employment  of  the 
vectis  always  requires  both  hands;  that  is,  while  one  hand  makes  traction 
on  the  handle  of  the  vectis,  the  fingers  of  the  other  hand  must  always  be 
placed  between    the  vagina  and  the  instrument  to  protect   the  tissues  from 
laceration.  , 

Reversed  Forceps. — A  far  better  operation,  when  manual  efforts  at  flexion 
have  failed,  is  to  be  found  in  the  application  of  reversed  forceps.  This  opera- 
tion is  in  reality  a  mere  extension  of  the  ancient  principle  that  the  tips  of  the 
forceps  should  always  be  directed  toward  the  leading  point  on  the  presenting 
part ;  but  when  the  forceps  is  applied  to  an  extended  head  in  a  posterior  posi- 
tion with  the  tips  directed  posteriorly,  its  grasp  is  directed  so  far  toward  the 
occipital  end  that  the  instrument  is  almost  certain  to  slip  after  flexion  has 
occurred.  It  is  therefore  important  to  remember  that  this  application  should 
be  utilized  only  for  the  production  of  flexion,  that  during  each  traction  the 
fingers  of  the  unemployed  hand  should  carefully  note  the  motions  of  the  , 
head,  and  that  as  soon  as  flexion  has  been  established  the  blades  should  be 
removed,  if  necessary  being  reapplied  for  the  delivery  of  the  head  in  the 
manner  recommended  for  the  delivery  of  a  well-flexed  head  in  posterior 
positions. 

Technique  of  the  Application  of  Reversed  Forceps. — The  forceps  should  be 
placed  outside  the  vulva,  in  the  position  in  which  they  are  to  lie  when  applied 
to  the  head — that  is,  with  the  transverse  axis  of  the  blades  at  right  angles  to 


THE   MECHANISM   OF  LABOR. 


505 


the  sagittal  suture,  and  with  the  tips  directed  backward.  If  the  lock  is  of 
the  ordinary  form,  the  handle  of  that  blade  which  would  be  the  left  in  the 
ordinary  position  should  be  held  in  the  right  hand,  and,  under  the  guidance 
of  two  fingers  of  the  left  hand,  should  be  inserted  into  the  vagina  and  passed 
into  position  as  near  as  possible  to  the  occipital  end  of  the  head  (Fig.  267). 


Fig.  267.— The  application  of  reversed  forceps.  The  arrow  indicates  the  effect  of  the  forceps  in  pro- 
moting the  descent  of  the  occiput  while  the  sinciput  is  delayed  by  friction  against  the  anterior  pelvic 
wall. 

The  other  blade  should  be  adjusted  to  correspond  with  its  fellow,  and  simple 
traction  upon  the  handles  should  be  made  in  the  direction  of  the  handles,  all 
leverage  motions  being  avoided.  The  force  of  the  instrument  is  then  directed 
against  the  occipital  end  of  the  head  alone ;  the  sinciput  is  delayed  by  the 
friction  of  the  pelvic  walls,  while  the  occiput  descends  under  the  force  of 
traction,  and  flexion  results. 

As  soon  as  the  small  fontanelle  has  been  brought  to  the  centre  of  the  pelvis 
— that  is,  when  the  head  has  been  flexed — the  forceps  should  be  removed  and 
the  process  of  rotation  be  entrusted  to  nature,  since  lacerations  of  the  vagina  are 
far  less  often  produced  when  rotation  is  effected  by  the  uterine  force  than 
when  it  is  procured  by  instrumental  means;  unless,  indeed,  the  condition  of 
the  patient  necessitates  an   immediate  delivery. 

Low  Forceps  in  Well-flexed  Heads  in  Posterior  Positions. — When  rotation 
fails  notwithstanding  the  presence  of  good  flexion — that  is,  when  a  well-flexed 
head  is  delayed  in  a  posterior  position  until  the  signs  of  exhaustion  occur — 
tin's  failure  is  usually  the  result  of  a  relative  want  of  vis-a-tergo,  which  must 
be  compensated  for  by  the  substitution  of  the  vis-a-fronte  of  the  forceps  ;  but 
it  is  the  first  essential  to  success  in  this  operation  that  the  instrument  should 
be  so  applied  that  its  presence  in  the  vagina  offers  no  impediment  to  the  rota- 
tion of  the  head.  If  in  this  position  of  the  head  the  forceps  is  applied  to  the 
sides  of  the  pelvis,  its  oblique  grasp  upon  the  forehead  and  the  occiput  will 
almost  certainly  prevent  rotation  ;  while,  even  if  it  is  applied  to  the  sides  of 
the  head,  it  is  liable  to  cause  extension  and  consequent  delay,  with  laceration 


506  AMERICAN  TEXT-BOOK   OF   OBSTETRICS. 

of  the  perineum,  and  frequently  the  death  of  the  fetus,  unless  special  precau- 
tions are  taken  to  ensure  its  grasping  the  occiput. 

So  long  as  the  occiput  is  distinctly  posterior  to  the  transverse  line  of  the 
pelvis,  the  forceps  should  be  applied  to  the  sides  of  the  head  with  the  concavity 
of  the  pelvic  curve  toward  the  forehead — that  is,  with  the  tips  anterior ;  but 
care  should  be  taken  during  the  application  of  the  blades  to  keep  the  handles 
well  raised,  or,  to  use  a  better  expression,  to  direct  the  tips  far  backward  into 
the  pelvis,  iu  order  to  ensure  their  grasping  the  occiput  and  thus  promoting 
rather  than  retarding  flexion  during  the  tractions.  The  tractions  should  be 
directed  as  far  backward  as  the  perineum  will  allow,  at  least  until  rotation 
has  occurred ;  since  it  is  sometimes  difficult  to  secure  this  line  of  traction 
in  the  ordinary  position  of  the  hands,  it  is  often  well,  in  the  extraction  of 
posterior  positions,  to  place  the  left  hand  upon  the  shanks  of  the  instrument 
near  the  vulva,  and  with  that  hand  draw  backward  while  the  right  hand 
steadies  the  extreme  end  of  the  handles. 

It  must  not  be  forgotten  that  the  maintenance  of  flexion  and  the  conse- 
quent production  of  rotation  are  essential  objects  of  this  first  application,  since 
descent  is  dependent  on  them. 

The  ^traduction  of  forced  rotation  by  a  rotative  movement  of  the  handles 
of  the  forceps  is  so  extremely  dangerous  to  the  soft  parts  of  the  mother  as  to 
be  permissible  to  uone  but  the  most  experienced  operators.  The  operator  who 
has  really  acquired  sufficient  skill  to  justify  such  a  maneuvre  will  infallibly 
have  acquired  so  active  an  impression  of  its  dangers  as  to  use  it  with  the  most 


Fig.  26S.— Lateral  motion  of  the  handles  of  the  curved  forceps  during  the  rotation  of  a  posterior  posi- 
tion of  the  head  :  A,  position  of  the  handles  when  first  applied ;  B,  position  of  the  handles  after  partial 
rotation  has  occurred. 

extreme  care ;  but,  though  an  active  rotation  force  is  not  permissible,  it  is 
always  proper,  and  indeed  necessary  to  success,  that  the  operator  should  avoid 
preventing  rotation.  He  should  know  exactly  the  motion  the  handles  will 
make  during  the  rotation  of  the  head,  as  that  occurs  under  the  guidance  of 
the  pelvic  grooves,  and  he  should  be  constantly  on  the  watch  to  promote  and 
favor  this  motion. 

Iu  this  connection  it  must  be  remembered  that  when  rotation  occurs  it  will 
be  in  the  axis  of  the  blades  and  not  in  that  of  the  handles,  so  that  as  the 
blades  rotate  their  handles  will  move  in  a  laterally  circular  direction  such  as 
is  illustrated  in  Figure  268.     If  a  good  pair  of  straight  forceps  is  at  hand,  it 


THE  MECHANISM   OF  LABOR.  507 

is  much  the  better  instrument  for  low  operations  in  posterior  positions,  since 
with  it  no  such  lateral  motion  of  the  handles  occurs,  and  the  avoidance  of  the 
necessity  of  watching  for  it  greatly  simplifies  the  operation. 

At  the  conclusion  of  each  traction  the  handles  of  the  forceps  should  be  sep- 
arated slightly,  since,  if  this  is  done,  the  head  not  infrecpiiently  rotates  to  an 
anterior  position  within  the  blades.  This  maneuvre  is  especially  useful  when 
the  original  application  of  the  forceps  has  been  slightly  inaccurate,  and  the 
head  is,  in  consequence,  not  grasped  exactly  on  its  sides.  A  careful  digital 
examination  should  always  be  made  at  the  conclusion  of  each  traction,  in 
order  to  note  exactly  the  mechanism  which  is  going  on,  to  become  aware  of 
rotation  as  soon  as  it  occurs,  and  to  detect  any  tendency  to  extension  which 
may  have  followed  a  faulty  application  of  the  forceps. 

As  soon  as  the  position  is  slightly  anterior,  or  even  when  it  becomes  trans- 
verse, the  forceps  should  be  removed  and  reapplied  to  the  sides  of  the  head, 
but  this  time  with  the  concavity  of  the  pelvic  curve  toward  the  occiput,  since 
any  further  rotation  with  the  blades  in  the  former  position  would  carry  them 
into  the  position  of  the  reversed  forceps,  in  which  the  grasp  is  unsatisfactory 
and  the  danger  of  laceration  is  great  from  the  too  close  apjDroach  of  the  tips  to 
the  posterior  wall  of  the  vagina.  The  tractions  should  again  be  intermittent, 
rotation  of  the  forceps  with  the  head  should  be  favored,  and  the  compression 
should  be  intermitted  during  the  intervals  between  the  tractions,  to  permit  the 
head  to  rotate  within  the  blades.  When  the  head  has  reached  the  O.  D.  A. 
position  the  forceps  should  again  be  removed,  and  reapplied  in  the  ordinary 
way,  unless  the  application  is  at  that  time  wholly  unsatisfactory.  The  operation 
as  a  whole  is  vastly  more  difficult  than  is  an  extraction  in  an  anterior  position. 

Delivery  in  Persistently  Posterior  Positions. — When,  from  any  cause,  the 
proper  maintenance  of  flexion  has  been  neglected,  and  the  occiput  has  settled 
into  the  hollow  of  the  sacrum — that  is,  where  it  has  become  directly  posterior 
— a  delivery  "  face  to  pubes "  is  all  that  can  be  hoped  for.  Under  these 
circumstances  delivery  by  the  natural  efforts  necessarily  implies  the  presence 
of  an  unusually  powerful  and  active  uterus.  It  is  necessary  for  the  pains  to 
force  the  head  into  extreme  flexion,  to  mould  it  into  a  much-changed  shape, 
and  to  distend  the  soft  tissues  to  an  extreme  degree  ;  and  the  vis-a-tergo  of  the 
uterus  must  usually  be  reinforced,  before  the  process  is  completed,  by  the  vis-a- 
fronte  of  the  forceps. 

The  first  duty  of  the  obstetrician  is  to  establish  an  extreme  flexion  by 
pressure  on  the  forehead  with  the  fingers  ;  it  will  then  be  maintained  by  nature 
if  the  uterus  is  powerful  enough  to  effect  an  unaided  delivery.  In  this  case 
an  attempt  to  preserve  the  perineum  by  keeping  the  occiput  well  forward 
against  the  pubes  is  his  ouly  other  duty ;  and  as  the  necessary  change  in  the 
shape  of  the  head  is  to  be  most  safely  effected  by  slow  moulding — that  is, 
during  a  long  second  stage — he  should  be  patient  and  loath  to  interfere ; 
indeed,  in  these  cases  the  use  of  the  forceps  is  never  warranted  unless  the  signs 
of  exhaustion  of  one  or  the  other  patient  are  clearly  present  and  increasing 
and  progress  has  ceased. 


508  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

If  the  forceps  must  be  used,  it  should  be  applied  to  the  sides  of  the  head, 
aud  the  extraction  should  be  effected  by  means  of  the  so-called  "  pump-handle 
traction."  The  tractions  should  at  first  be  directed  well  backward  until  the 
perineum  distends,  in  order  to  draw  the  occiput  downward  along  the  posterior 
pelvic  wall,  and  then  should  sweep  forward,  in  order  to  draw  it  forward  over 
the  pelvic  floor  to  the  vulva  and  the  arch  of  the  pubes.  These  tractions 
should  be  gentle  and  intermittent,  in  order  to  encourage  a  slow  moulding  of 
the  head,*  and  the  forward  direction  should  be  maintained  until  the  small 
fontanelle  appears  at  the  fourchette  and  the  perineum  retracts  along  the  neck. 
The  handles  of  the  forceps  should  then  be  moved  backward,  but  without  inter- 
mission of  the  traction,  in  order  to  favor  the  appearance  of  the  face  from 
under  the  pubic  arch  by  extension  as  in  natural  labor. 

2.  Face  Presentations. 

Frequency. — A  face  presentation  is  not  a  very  common  anomaly.  Pinard 
found  320  face  cases  out  of  81,711  deliveries  at  the  Paris  Maternite — a  fre- 
quency of  about  1  iu  250.  At  Guy's  Hospital  Lying-in  Charity,  London, 
there  was  a  frequency  of  1  in  276,  or  .36  per  cent,  out  of  23,591  cases  of 
labor.  Churchill  analyzed  about  250,000  cases,  and  found  that  face  presen- 
tations averaged  1  iu  231.  Collins  at  the  Dublin  Rotunda  found  the  fre- 
quency to  be  1  in  497.    Spiegelberg  thought  that  in  Germany  it  was  1  in  324. 

Relative  Frequency  of  the  Positions. — M.  L.  A.  is  but  very  slightly  more 
frequent  than  M.  D.  P.     M.  D.  A.  and  M.  L.  P.  are  very  rarely  seen. 

Etiology. — Face  presentations  are,  of  course,  produced  by  the  extension  of 
vertex  presentations  at  or  just  before  the  beginning  of  labor,  and  every  face 
presentation  has  therefore  passed  through  the  stage  of  brow  before  becoming  a 
face  presentation.  Many  factors  may  contribute  to  the  production  of  this  ex- 
tension, and  it  is  probable  that  the  etiology  of  the  anomaly  varies  widely  in 
different  cases.  It  may  be  originated  by  an  abnormal  shape  of  the  head,  by  an 
obliquity  or  abnormality  of  the  uterus,  by  small  tumors  in  or  about  the  pelvic  brim, 
by  a  deformity  of  the  pelvis,  or  by  an  over-tight  adaptation  between  the  head 
and  the  brim  in  a  posterior  position  of  the  vertex. 

Undue  Length  of  the  Hind-head. — Any  abnormal  prominence  of  the  occi- 
put necessarily  lengthens  the  short  arm  of  the  cephalic  lever,  and  therefore 
tends  to  the  production  of  extension.  The  presence  of  such  an  anomaly  would 
undoubtedly  predispose  to  a  face  presentation,  and  cases  have  been  reported  in 
which  it  was  apparently  the  sole  cause  ;  but  in  the  majority  of  face  cases  the 
head  is  found  to  be  of  normal  shape  after  the  moulding  of  labor  has  passed 
away,  and  was  therefore  probably  normal  at  the  beginning  of  labor. 

Obliquity  or  Abnormality  of  the  Uterus.. — An  obliquity  of  the  uterine  axis 
by  which  the  fundus  is  inclined  to  the  side  on  which  lies  the  back  of  the  child 
tends  to  roll  the  condyles  to  the  opposite  side  of  the  pelvis  by  altering  the 

*  Since  the  chief  danger  in  this  operation  is  that  of  inhibiting  the  life  of  the  fetus  by  com- 
pression of  its  skull  against  the  pubes,  it  is  well  to  have  the  fetal  heart  watched  by  an  assistant, 
and  to  regulate  the  force  of  the  tractions  by  the  effect  produced  upon  its  beat. 


THE  MECHANISM    OF  LABOR. 


509 


Fig.  269.— Manner  in  which  an  obliquity  of  the 
uterine  axis  may  produce  a  face  presentation. 


direction  of  the  uterine  force  (Fig.  269),  in  which  the  condyles  are  urged 
(in  the  direction  of  the  arrow)  by  the  uterus,  and  thus  produces  extension. 
Again,  any  irregularity  in  the  contour  of  the  uterine  wall  on  the  side  to  which 
the  occiput  is  directed — for  example,  a 
cicatrix  or  a  localized  tonic  constriction 
— may  delay  its  progress  and  so  pro- 
duce extension. 

Small  Tumors  in  the  Brim.— A.  tu- 
mor which  impedes  the  advance  of  the 
occiput,  but  does  not  interfere  with  the 
sinciput,  may  be  the  cause  of  a  face 
presentation. 

Pelvic  Deformities.  —  The  minor 
grades  of  flattened  pelvis  in  which 
moderate  extension  at  the  brim  is  nor- 
mally present  (see  Dystocia)  are  a  fre- 
quent cause  of  face  presentations. 

Tight  Adaptation  in  the  Posterior 
Positions  of  Vertex  Presentations. — We 
have  seen  (p.  493)  that  there  is  a 
marked  tendency  to  the  production  of  extension  at  the  brim  in  O.  D.  P.  and 
O.  L.  P.  positions.  That  this  is  a  frequent  cause  of  face  presentation  is  shown 
by  the  fact  that,  although  an  O.  D.  P.  occurs  but  about  once  in  every  four 
vertex  labors,  the  results  of  its  extension — that  is,  an  M.  L.  A. — make  up 
nearly  one-half  of  all   face   labors. 

Diagnosis. — On  abdominal  examination  the  fetal  limbs,  the  heart,*  and 
the  least  accessible  portion  of  the  head  are  found  on  the  same  side.  On  vagi- 
nal examination  with  the  finger,  the  pointed  chin,  the  mouth  with  its  maxillary 
processes  and  the  tongue,  the  nostrils,  the  bridge  of  the  nose,  the  eyes,  and  the 
supraorbital  ridges  should  be  found  and  recognized.  The  position  is  deter- 
mined by  the  position  of  the  chin. 

Prognosis. — The  prognosis  in  face  presentations  for  both  mother  and  child 
is  always  somewhat  worse  than  in  vertex  labor,  but  it  varies  greatly  in  accord- 
ance with  the  position  of  the  chin,  the  prognosis  of  anterior  positions  being 
vastly  better  than  that  of  posterior  positions.  The  mortality  of  face  presenta- 
tions varies  also  between  extremely  wide  limits,  in  accordance  with  the  varia- 
tions in  the  adaptation  between  the  head  and  the  pelvis,  and  more  especially 
with  the  degree  of  ossification  of  the  fetal  head. 

When  the  chin  is  anterior,  when  the  adaptation  between  the  head  and  the 
pelvis  is  moderately  easy,  and  the  fetal  head  is  so  soft  as  to  permit  of  an  easv 
production  of  the  necessary  change  of  shape,  face  labor  is  apt  to  be  rapid.  The 
prognosis  for  the  mother  is  then  unaltered  from  that  of  good  normal  labor, 
and  the  prognosis  for  the  child  is  but  little  worse ;  but  this  statement  is  true 
only  -when  the  conditions  are  such  that  there  is  rapid  progress  throughout  the 

*  In  face  presentations  the  heart  is  heard  over  the  ventral  side  of  the  chest. 


510 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


second  stage :  with  the  supervention  of  any  delay  the  prognosis  for  the  child 
becomes  decidedly  poor,  while  at  the  same  time  the  mother's  prospects  are 
rendered  less  good  by  the  risks  of  laceration  during  rotation  that  are  always 
involved  in  a  difficult  or  operative  delivery  of  the  face. 

In  posterior  positions  of  the  chin  the  prognosis  for  the  child  is  always  poor, 
since  under  the  most  favorable  circumstances  it  is  necessarily  exposed  to  the 
utmost  danger,  both  from  the  marked  compression  of  the  cranium  against  the 
symphysis  that  invariably  occurs  and  from  the  great  tension  upon  the  tissues  of 
the  neck  that  is  implied  in  the  extreme  extension  necessary  to  excite  rotation 
in  posterior  positions  of  the  face.  With  any  but  the  most  extremely  favorable 
conditions  the  prognosis  for  the  child  in  posterior  positions  of  the  face  is 
almost  necessarily  fatal,  while  that  for  the  mother  is  complicated  by  the  proba- 
bility of  extensive  lacerations.  In  the  large  majority  of  such  cases  rotation 
fails,  and  the  child's  case  is  then  practically  hopeless,  since  no  instance  has  yet 
been  recorded  iu  which  the  child's  life  was  preserved  duriug  the  extraction  of 
a  persistently  posterior  position  of  the  face. 

Mechanism  and  Management  of  Face  Presentations. 

Mechanism  of  Pace  Presentations. — Iu  the  mechanism  of  face  presenta- 
tions the  chin  plays  the  same  ?'6k  that  the  occiput  does  in  vertex  labor.  Rotation 
is  as  necessary  to  expulsion  in  the  one  case  as  in  the  other,  and  the  occurrence 
of  rotation  depends  on  the  fact  that  under  normal  conditions  the  chin  enters 
more  deeply  into  the  pelvis  than  the  most  prominent  point  upon  the  other  side 

of  the  head,  which  in  this  case  is  that 
portion  of  the  forehead  immediately 
anterior  to  the  bregma.  This  deeper 
entrance  of  the  chin  is  in  face  presenta- 
tion secured  only  by  the  existence  of 
complete  extension,  and  extension  is 
even  more  important  to  progress  dur- 
ing the  second  stage  of  face  labor  than 
is  flexiou  during  the  second  stage  of 
vertex  labor. 

Mechanism  of  Face  Presentations, 
31.  L.  A. — Fully-developed  face  pres- 
entations at  the  beginning  of  labor 
are  comparatively  rare.  The  face 
commonly  starts  as  a  vertex,  passes 
through  the  stage  of  a  brow  while  still 
unengaged,  and  becomes  a  face  presentation  only  during  the  passage  of 
the  brim.  By  .reference  to  Figure  270,  which  represents  the  position  of 
the  head  during  the  passage  of  the  brim  by  a  face  presentation,  it  will 
be  seen  that  after  the  point  of  the  chin  has  passed  the  pelvic  brim  the 
ventral  side  of  the  head  and  the  neck  is  so  shaped  as  to  offer  but  little 
opportunity  for  the  engendering  of  friction  against  the  pelvic  wall,  while  the 


-Presentation  of  the  face  at  the  pelvic 
brim. 


THE   MECHANISM   OF  LABOR. 


511 


shape  of  the  projecting  forehead  and  bregmatic  region  is  such  as  to  ensure 
firm  pressure  between  them  and  that  part  of  the  pelvis  opposite.  The  posi- 
tion of  the  head  brings  its  articulation  with  the  spinal  column  far  out  to  the 


Fig.  271.— Face  presentation  at  outlet  after  rotation  (Smellie). 

ventral  side  of  the  head,  and  we  have  then  the  pressure  of  the  propelling  force 
concentrated  far  out  to  one  side  in  the  head,  while  the  resisting  force  of  friction 
against  the  pelvic  walls  is  exerted  almost  wholly  upon  the  other  side ;  hence 
good  extension  is  the  rule  in  face  labor.     The  existence  of  complete  extension, 


Fig.  272.— Configuration  of  the  fetal  head  after  its 
delivery  as  a  face  presentation. 


.—Configuration  of  the  fetal  head  after  its 
delivery  as  a  vertex  presentation. 


however,  places  so  great  a  strain  upon  the  tissues  of  the  neck  that  its  produc- 
tion is  usually  accomplished  slowly ;  and  the  diameter  which  must  occupy  the 
brim  as  the  head  descends — namely,  the  cervico-bregmatic  (Fig.  270)— is  so 


512  AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 

large  that  with  reasonably  tight  adaptation  the  descent  of  the  face  is  usually 
accomplished  at  the  expense  of  considerable  moulding  of  the  head  (Fig.  272). 

The  cervico-bregmatic  diameter  of  the  head  is  so  far  behind  the  leading 
point,  the  chin,  that  by  the  time  the  head  is  free  from  the  superior  strait — 
that  is,  when  this  great  diameter  passes  it — the  chin  is  already  deep  in  the 
pelvis,  and,  indeed,  by  this  time  occupies  the  deepest  portion  of  the  ante- 
rior groove  of  the  left  lateral  wall.  At  this  point  there  is  often  a  temporary 
dead-lock,  since  the  great  elongation  of  the  head  may  still  leave  the  region 
of  the  sagittal  suture  in  the  sacro-iliac  notch,  where  it  is  prevented  by  the 
promontory  from  turning  backward,  although  the  chin  is  being  urged  strongly 
forward  by  the  lower  portion  of  the  anterior  groove. 

Rotation  can  then  occur  only  when  the  propelling  force  is  sufficiently  strong 
to  crowd  the  chin  downward  to  the  lowest  possible  point,  and  may  even  require 
a  further  lateral  moulding  of  the  head  under  the  pressure  of  the  promontory 
against  the  projecting  occiput. 

As  soon  as  the  occiput  slips  under  the  promontory  rotation  promptly  occurs. 
The  chin  swings  under  the  pubic  arch  (Fig.  271),  and  the  mouth,  the  nose,  the 
eyes,  and  the  forehead  successively  appear  at  the  fourchette.  When  the  angle 
of  the  jaw  rests  against  the  descending  rami  of  the  pubes,  the  chin  and  the  face 
become  wholly  freed  from  pressure,  while  the  occiput  is  still  exposed  to  the 
propelling  power  of  the  uterine  force  from  above.*  The  chin  then  sweeps 
upward,  and  as  the  occiput  continues  to  progress,  the  bregma,  the  small 
fontauelle,  and  the  occiput  successively  appear  at  the  fourchette,  and  the  head 
emerges  by  flexion. 

The  mechanism  of  face  labor  is,  then,  extension,  descent,  rotation,  and  birth 
by  flexion.  Restitution  carries  the  chin  to  the  side  to  which  it  was  originally 
directed  during  the  expulsion  of  the  shoulders.  The  mechanism  of  31.  D.  A. 
labor  is,  of  course,  similar  to  that  of  M.  L.  A. 

The  Mechanism  of  Posterior  Face  Presentations.  M.  D.  P. — The  chin 
enters  the  posterior  groove  at  the  brim,  and  should  travel  forward  along  its 
course ;  but  even  when  extension  is  complete  the  production  of  so  extensive  a 
rotation  as  is  necessary  to  bring  the  chin  to  the  front  is  rendered  extremely 
difficult  by  the  marked  obstacle  afforded  to  its  performance  by  the  resistance 
of  the  very  prominent  bregmatic  region,  which,  notwithstanding  its  size  (Fig. 
274),  must  be  made  to  travel  backward  along  the  whole  left  lateral  surface  of 
the  brim — a  motion  possible  only  when  the  propelling  forces  are  sufficiently 
powerful  and  the  head  is  sufficiently  soft  to  permit  the  production  of  a  very 
extreme  degree  of  moulding  of  the  head.  When  rotation  has  once  carried  the 
chin  into  an  anterior  position,  the  mechanism,  of  course,  is  that  of  a  primary 
M.  D.  A.    No  separate  description  of  the  M.  L.  P.  mechanism  need  be  given. 

Management  of  Pace  Presentations. — Management  of  Face  Presentations 

at  the  Brim. — The  measures  which  must  be  considered  in  the  management  of  face 

presentations  when  detected  while  the  child  is  still  in  or  above  the  brim  are  as 

follows  :  The  case  may  be  left  to  nature;  an  attempt  may  be  made  to  raise  the 

*  Through  the  intrauterine  fluid  pressure. 


THE   MECHANISM    OF  LABOR. 


513 


chin,  and  so  restore  a  vertex  presentation  by  manual  flexion  of  the  head,  after 
which  it  may  be  left  to  nature  or  be  delivered  by  the  forceps ;  forceps  may  be 
applied  to  the  face  as  such,  or  the  case  may  at  once  be  delivered  by  version. 

Natural  Labor. — The  first  expedient,  that  of  leaving  the  case  to  the  care 
of  nature,  is  applicable  only  under  one  set  of  circumstances.     When  the  chin 


Fig.  274.— Posterior  position  of  the  face  deeply  engaged  in  the  pelvis  (Smellie). 


is  anterior  ;  when  the  woman  is  a  multipara  who  has  had  a  succession  of  easy 
labors ;  when  the  accoucheur  is  able  to  satisfy  himself  by  a  thorough  examina- 
tion that  the  soft  parts  are  soft  and  dilatable,  that  the  pelvis  is  ample,  and  that 
the  child  is  small,  the  latter  point  having  been  determined  not  only  by  palpation 
of  the  abdomen,  but  also  by  palpation  of  the  head  with  the  half  hand  introduced 
into  the  vagina ;  when  the  uterus  is  powerful  and  the  pains  are  frequent ;  and, 
finally,  when  no  pathological  complication  is  present, — it  is  often  wise  to  adopt 
a  conservative  policy ;  but  the  consequences  of  delay  are  so  serious  even  in 
anterior  positions  of  the  face,  and  the  prediction  of  an  easy  labor  is  always  so 
difficult,  that  the  obstetrician  should  feel  that  in  making  this  prediction  and 
adopting  a  policy  of  inaction  he  is  taking  a  veiy  grave  responsibility.  When 
the  chin  is  posterior,  or  when,  in  anterior  positions,  the  couditions  are  anything 
but  the  most  favorable,  it  should  be  the  rule  that  the  detection  of  a  face  pres- 
entation at  the  brim  is  to  be  followed  by  immediate  interference. 

Interference  at  the  Brim. — The  choice  of  methods  rests  between  manual 
flexion  of  the  head  into  a  vertex  presentation,  version,  and  the  application  of 
forceps  to  the  face. 

The  choice  between  version  and  the  production  of  a  head  presentation  by 
manual  flexion  rests  mainly  on  the  position  of  the  chin.  If  the  chin  is  pos- 
terior, flexion  of  the  head  will  result  in  the  production  of  an  anterior  position 

33 


514  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

of  the  vertex — the  most  favorable  position  for  a  subsequent  delivery  by  nature 
or  for  an  extraction  by  the  forceps ;  if  the  chin  is  anterior,  flexion  can  produce 
only  the  unfavorable  posterior  position  of  the  vertex. 

In  posterior  positions  of  the  chin  manual  flexion  should  ordinarily  be  the 
first  expedient,  and  the  head,  when  flexed,  should  be  urged  into  the  brim  by 
external  pressure  with  the  hand,  in  the  hope  that  it  may  become  engaged  in 
this  position  under  the  influence  of  the  pains,  after  which  the  case  should,  of 
course,  be  left  to  nature  ;  but  if  an  engagement  does  not  follow  promptly,  it  is 
best  to  apply  forceps  at  once,  since  the  conditions  which  originally  produced 
the  face  presentation  may  usually  be  relied  upon  to  reproduce  it.  If  the  manual 
reproduction  of  a  vertex  presentation  proves  difficult  or  impossible,  the  attempt 
should  be  abandoned  and  version  be  performed. 

If  the  chin  is  anterior,  flexion  of  the  head  would  result  in  the  production 
of  a  posterior  position  of  the  vertex ;  and  since,  as  has  been  seen,  posterior 
positions  of  the  vertex  at  the  brim  are  frequently  best  treated,  when  interference 
is  necessary,  by  a  resort  to  version,  it  follows  that  in  anterior  positions  of  the 
chin,  when  interference  is  necessary,  a  primary  version  is  the  operation  of 
choice.  When  in  such  cases  a  version  is  contra-indicated,  the  choice  lies  between 
an  application  of  the  forceps  to  the  face  and  a  manual  flexion  iuto  a  poste- 
rior position  of  the  vertex,  to  be  followed  by  an  attempt  at  a  manual  rota- 
tion of  the  occiput  to  the  front  and  the  application  of  forceps.  If  the 
conditions  are  such  as  to  render  this  latter  operation  possible,  it  is  generally 
preferable  to  the  use  of  forceps  to  the  face ;  but  since  the  conditions  which 
contra-indicate  version  very  generally  render  manual  rotation  of  the  head  diffi- 
cult or  impossible,  it  will  sometimes  be  necessary  to  resort  in  such  cases  to  the 
use  of  forceps  to  the  face. 

The  use  of  forceps  to  the  face  at  the  brim  is  always  a  difficult  operation. 
The  delivery  of  the  child  through  the  brim  without  injury  to  either  mother  or 
child  can  be  accomplished  only  by  the  utmost  accuracy  in  the  adjustment  of 
the  blades ;  and  even  in  anterior  positions  the  prognosis  is  serious.  The  use 
of  forceps  to  the  face  high  is,  then,  never  permissible  to  any  but  a  thoroughly 
skilled  operator,  and  even  in  such  hands  it  should  be  reserved  for  a  last  resort. 
In  posterior  positions  the  forceps  is  never  permissible,  and  it  should  be  forbid- 
den both  from  its  inherent  difficulties  and  because  success  in  the  passage  of 
the  brim  can  only  result  in  the  production  of  that  very  dangerous  condition, 
a  posterior  position  of  the  face  within  the  excavation. 

Management  of  Face  Presentations,  Low. —  Chin  Anterior. — When  a  face 
presentation  has  been  allowed  toxpass^]ieLrim  or  has  not  been  discovered  untils 
it  is  within  the  excavation,  its  prog^ss  showM  be  watched  with  great  care,  and 
the  utmost  pains  must  be  taken  to  nSaintai/  complete  extension  throughout  the 
second  stage.  A  constant  watch  over^tne  processes  of  nature  must  be  main- 
tained, since  any  considerable  delay  is  attended  by  great  danger  to  the  life  of 
the  child,  from  the  likelihood  that  an  interruption  of  its  cerebral  circulation 
may  occur  as  a  result  of  the  extreme  tension  necessarily  put  upon  the  vessels 
of  the  neck  or  of  their  compression  against  the  sides  of  the  pelvis. 


THE  MECHANISM   OF  LABOR.  515 

It  follows  from  these  dangers  that  even  moderate  delay  furnishes  a  sufficient 
indication  for  the  use  of  low  forceps  in  face  presentations.  Complete  exten- 
sion, as  has  been  said,  is  of  the  utmost  importance,  and,  fortunately,  may  easily 
be  maintained  by  pressure  with  the  fingers  upon  the  under  surface  of  the  lower 
jaw.  Should  interference  become  necessary,  it  is  absolutely  important  that  the 
forceps  should  be  applied  to  the  sides  of  the  cranium,  and  with  the  tips  so  far 
posterior  as  to  be  entirely  clear  of  the  neck.  In  anterior  positions,  if  this 
necessity  be  borne  in  mind,  the  application  of  forceps  is  easy,  and  the  extraction 
of  the  child  ordinarily  presents  no  great  difficulties ;  but  it  must  not  be  for- 
gotten that  pressure  upon  the  tissues  of  the  neck  by  the  tips  of  the  blades  must 
almost  invariably  result  in  loss  of  the  child. 

Chin  Posterior. — As  has  been  said,  the  face  should  never  be  allowed  to  enter 
the  pelvis  chin  posterior.  If  this  abnormality  is  not  discovered  until  it  has 
occurred,  the  patient  should  at  once  be  etherized,  the  hand  be  introduced,  and 
the  possibility  of  raising  the  head  above  the  brim  should  be  tested.  If  this 
is  possible  without  grave  risk  to  the  mother,  it  should  at  once  be  done,  and  the 
face  dealt  with  according  to  the  principles  already  outlined  for  the  operative 
treatment  of  the  face  high  (p.  513). 

If  elevation  of  the  head  proves  impossible,  the  obstetrician  should  content 
himself  with  the  maintenance  of  extreme  extension  by  traction  upon  the  chin 
in  combination  with  a  constant  attempt  to  promote  rotation  by  drawing  the 
chin  forward  with  the  fingers.  This  process  should  be  persisted  in  so  long  as 
there  is,  in  his  judgment,  any  possibility  of  rotation.  When  this  prospect 
becomes  hopeless,  forceps  may  be  applied  and  an  attempt  be  made  to  extract 
the  face  as  a  persistently  posterior  chin  presentation. 

Any  attempt  at  rotation  by  the  forceps  must  be  forbidden,  both  because  of 
the  grave  danger  of  provoking  extensive  lacerations  of  the  mother  that  neces- 
sarily attends  this  maneuvre,  and  because  any  slipping  of  the  blades  upon  the 
child  or  any  oblique  application  of  the  forceps  would  necessarily  involve  com- 
pression of  the  vessels  of  the  fetal  neck,  and  therefore  the  loss  of  the  fetus.  A 
straight  forceps  should  be  used  if  it  is  at  hand.  It  should  be  applied  care- 
fully to  the  sides  of  the  head  and  with  the  tips  well  anterior,  so  that  the  grasp 
of  the  blades  may  be  wholly  upon  the  cranial  vault.  The  tractions  should  be 
directed  slightly  backward  until  the  perineum  is  thoroughly  upon  the  stretch, 
then  forward  and  upward  until  the  chin  emerges,  and  then  well  downward,  that 
the  occiput  may  emerge  under  the  arch  and  the  head  be  born  by  flexion.  Since 
lacerations  of  the  pelvic  floor  are  inevitable  in  this  operation,  and  since  every 
possible  advantage  must  be  taken,  the  perineum  should  be  incised  by  deep  lat- 
eral incisions  as  a  preliminary  measure. 

This  process  has  not  yet  been  successful  in  the  extraction  of  a  living  child  ; 
but  since  it  has  never,  so  far  as  known,  been  adopted  while  the  child  was  in 
good  condition,  and  as  it  has  several  times  succeeded  in  extracting  dead  but 
uninjured  children,  it  deserves  a  more  extended  trial  whenever  a  child  in  this 
position  is  still  in  fairly  good  condition.  If  the  child's  vitality  is  already  seri- 
ously compromised,  its  chances  of  life  are  so  small  that  the  prospect  of  preserv- 


516  AMERICAN   TEXT- BOOK    OF    OBSTETRICS. 

ing  the  mother's  soft  tissues  would,  in  the  judgment  of  most  obstetricians, 
justify  the  choice  of  craniotomy.* 

3.  Brow  Presentations. 

Frequency. — As  face  cases  have  usually,  if  not  invariably,  passed  through 
the  stage  of  brow  in  the  process  of  their  conversion  from  a  vertex  presentation, 
temporary  presentations  of  the  brow  must  be  at  least  as  frequent  as  those  of 
the  face  ;  but  if  only  those  brow  presentations  which  remain  such  until  altered 
by  the  obstetrician  are  included  in  the  list,  the  frequency  becomes  less — pro- 
bably not  more  than  1  in  1500  labors. 

Relative  Frequency  of  the  Positions. — Brow  O.  L.  A.  and  brow  O.  D.  P.  are 
almost  equally  frequent.     The  others  are  much  less  common. 

Etiology. — Brow  presentations  are  due  to  the  same  causes  that  produce 
presentations  of  the  face  (p.  508),  but  it  is  of  course  a  fact  that  if  the  process 
of  extension  is  arrested  in  the  stage  of  brow,  it  implies  a  greater  obstacle  to  the 
progress  of  the  head  than  where  nature  is  able  to  develop  a  face  presentation. 

Diagnosis. — On  abdominal  examination  the  two  ends  of  the  head  are  found 
at  about  the  same  level,  and  the  heart  is  usually  heard  over  the  back.  On 
vaginal  examination  the  small  fontanelle  is  found  at  one  end  of  the  field,  the 
large  fontanelle  in  its  centre,  and  the  supraorbital  ridges  on  the  other  side. 

Prognosis. — Siuce  at  term  and  with  a  normal  head  the  spontaneous  delivery 
of  an  unchanged  brow  presentation  is  possible  only  after  a  degree  of  prolonga- 
tion of  labor  that  is  disapproved  by  modern  obstetrics,  the  prognosis  of  per- 
sistent brow  presentations  for  both  mother  and  child  is  that  of  the  operation 
chosen.  It  should  be  remembered,  however,  that  when  nature  changes  the 
brow  to  a  face  the  prognosis  becomes  that  of  a  face  presentation. 

Mechanism  and  Management  of  Brow  Presentations. 

Mechanism  of  Presentations  of  the  Brow. — Anterior  Position  of  the  Brow 

{that  is,  brow  0.  D.  P.  and  brow  0.  L. 
P.). — In  the  rare  cases  in  which  a  pres- 
entation of  the  brow  succeeds  in  enter- 
ing the  pelvis,  this  possibility  is  due  to 
the  fact  that  the  moulding  of  the  head 
has  progressed  until  the  occipito-mental 
diameter  has  become  sufficiently  small 
to  pass  the  oblique  at  the  brim,  and  this 
change  is  compensated  for  by  a  corre- 
sponding increase  in  the  occipito-frontal 

Fig.  275.— Configuration  of  the  fetal  head  after  its        i-  *"    /-n.        nr-_N        rru 

delivery  as  a  brow  presentation.  diameter  (Fig.  2/5).     The  increase  in 

the  length  of  this  diameter  necessarily 

carries  the  forehead  much  deeper  into  the  pelvis  than  any  other  part  of  the 

*  Since  the  above  was  written  the  great  success  of  symphysiotomy  has  led  most  obstetricians 
to  believe  that  a  division  of  the  symphysis  should  precede  all  applications  of  the  forceps  to  a 
persistently  posterior  position  of  the  face. 


THE  MECHANISM   OF  LABOR.  517 

head,  so  that  m  anterior  jrositions  of  the  brow  the  projecting  forehead  engages 
in  the  anterior  groove  of  the  lateral  pelvic  wall  as  soon  as  the  brim  has  been 
passed,  and  reaches  its  deeper  part  by  the  time  the  occiput  escapes  from  the 
sacro-iliac  notch  and  enters  the  shallow  upper  part  of  the  posterior  groove  of 
the  opposite  pelvic  wall. 

If  the  conditions  are  so  exceptionally  favorable  as  to  permit  of  the  expul- 
sion of  an  unchanged  brow  presentation,  the  forehead  moves  forward  aloug 
the  course  of  the  anterior  groove,  while  the  occiput,  beiug  still  in  the  shallow 
upper  part  of  the  posterior  groove  of  the  opposite  side,  moves  back  into  the 
hollow  of  the  sacrum  ;  the  root  of  the  nose  comes  to  the  pubic  arch,  and  the 
progress  of  the  anterior  portion  of  the  head  is  then  arrested,  while  the  occiput 
travels  down  along  the  posterior  wall  of  the  pelvis  and  across  the  perineum. 
The  nose  and  the  chin  then  appear  beneath  the  pubic  arch,  and  the  head  in 
anterior  positions  of  the  brow  is  thus  expelled  by  extension.  External  rota- 
tion, of  course,  carries  the  occiput  to  the  side  to  which  it  was  originally 
directed. 

Posterior  Positions  of  the  Brow  (that  is,  brow  0.  L.  A.  and  brow  0.  D.  A.). 
— Should  an  unchanged  posterior  position  of  the  brow  succeed  in  passing  the 
brim,  the  forehead  would  enter  the  posterior  groove  and  the  occiput  would 
lie  against  the  shallow  portion  of  the  anterior  groove.  If  the  case  went  on  to 
delivery,  the  rotation  of  the  forehead  along  the  posterior  groove  would  be 
similar  to  that  of  the  occiput  in  occipito-posterior  positions  of  the  vertex  ;  but 
when  the  enormous  difficulties  incident  to  the  expulsion  of  the  brow  under  the 
most  favorable  circumstances  are  increased  by  the  inherent  difficulties  always 
attached  to  rotation  in  posterior  positions,  the  sum-total  of  the  obstacle  becomes 
so  great  that  a  delivery  is  almost  unknown,  and  it  may  be  laid  down  as  a  practi- 
cal rule  that  posterior  positions  of  the  brow  always  become  arrested. 

Management  of  Brow  Presentations :  Management  at  the  Brim. — 
When  a  brow  presentation  is  detected  at  the  brim,  we  may  deal  with  it  by  any 
one  of  the  four  following  methods  :  the  case  may  be  left  to  the  care  of  nature  ; 
the  brow  may  be  converted  into  a  vertex  by  manual  flexion  ;  the  brow  may  be 
changed  into  a  face  by  manual  extension ;  or  the  case  may  be  delivered  by 
immediate  version.  The  choice  between  these  methods  of  treatment  depends 
primarily  on  the  position,  but  in  posterior  positions  of  the  brow — that  is,  when 
the  occiput  is  anterior — the  indications  are  considerably  modified  by  the  pres- 
ence of  excessive  moulding  of  the  presenting  part. 

Anterior  Positions  of  the  Brow. — The  class  of  cases  which  should  be  left 
to  the  care  of  nature  is  extremely  limited,  and  includes  only  those  few  cases 
of  anterior  positions  of  the  brow  which,  when  detected,  are  rapidly  changing 
into  anterior  positions  of  the  face,  and  in  which  the  conditions  of  the  case  are 
such  that,  if  the  face  becomes  established,  its  progress  is  certain  to  be  rapid 
and  easy.  Flexion  of  such  a  brow  would  produce  a  posterior  position  of  the 
vertex,  and  there  is  then  but  little  hope  of  a  spontaneous  delivery  of  the  uew 
presentation,  since  the  marked  tendency  to  extension  which  always  character- 
izes the  posterior  positions  of  the  vertex  would  almost  certainly  reproduce  the 


518  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

brow,  while  if  an  operative  delivery  is  to  be  undertaken,  version  is  the  opera- 
tion of  election  in  posterior  positions  of  the  vertex.  It  follows  that  version 
is  the  operation  of  choice  in  anterior  positions  of  the  brow  (see  Management 
of  Face  Presentations  at  the  Brim,  p.  512). 

All  other  anterior  positions  of  the  brow  should  be  dealt  with  by  immediate 
version  as  the  operation  of  choice,  the  production  of  a  vertex  by  manual  flex- 
ion being  ruled  out  for  the  following  reasons  : 

In  freeing  a  partially-engaged  brow  from  the  brim  of  the  pelvis  as  a  pre- 
liminary to  version,  it  is  essential  that  the  first  effort  at  raising  the  head  should 
be  directed  against  the  forehead,  since  a  preliminary  flexion  of  the  head  re- 
places the  long  occipito-mental  diameter  by  the  shorter  occipito-frontal  diam- 
eter, and  the  subsequent  elevation  of  the  head  therefore  exposes  the  tissues  of 
the  mother  to  far  less  risk  than  would  be  involved  in  an  attempt  to  force  the 
extended  occipito-mental  diameter  bodily  upward.  Moderate  flexion  is,  more- 
over, an  important  element  to  success  in  the  subsequent  manipulations  of  the 
version,  since  its  production  minimizes  the  obstacle  offered  by  the  projecting 
sinciput. 

When  in  anterior  positions  of  the  brow  which  promise  a  difficult  delivery 
an  attempt  at  version  fails,  a  manual  extension  of  the  brow  to  an  anterior  posi- 
tion of  the  face,  to  be  followed  by  forceps,  is  the  only  alternative  to  craniotomy, 
unless  the  condition  of  the  child  warrants  a  resort  to  one  of  the  major  cutting 
operations  (see  The  Use  of  Forceps  to  the  Face  at  the  Brim,  p.  514). 

When  the  brow  presents  in  a  posterior  position — that  is,  with  the  occiput 
anterior  and  with  the  head  unmoulded — its  treatment  by  manual  flexion  results 
in  the  production  of  an  anterior  position  of  the  vertex,  and  a  manual  flexion 
is  therefore  in  these  cases  the  operation  of  choice.  After  the  re-establishment 
of  flexion  the  head  should  be  held  in  position  by  the  hands  for  a  few  pains ; 
but,  unless  its  engagement  occurs  promptly,  it  is  usually  best  to  resort  to  an 
immediate  application  of  the  forceps,  since  it  may  fairly  be  presumed  that  the 
conditions  which  originally  led  to  the  loss  of  flexion  are  still  present,  and  will 
probably  reproduce  the  extension  if  the  case  is  left  to  itself.  In  this  position 
of  the  brow  a  manual  extension  is  contra-indicated,  since  it  could  only  result  in 
the  production  of  a  posterior  variety  of  the  face,  which  in  itself  is  so  danger- 
ous that  it  demands  an  immediate  version.  If,  therefore,  in  these  cases  a 
manual  flexion  is  ruled  out,  version  should  again  be  selected  as  the  operation 
of  second  choice. 

When  the  brow  presents  in  a  posterior  jjosition — that  is,  with  the  occiput 
anterior  and  with  the  head  already  much  moulded — the  operation  of  manual 
restoration  of  the  vertex  must  be  ruled  out  in  the  interest  of  the  child,  for  the 
following  reasons:  First,  if  a  marked  change  of  shape  is  apparent  at  the  time 
the  presentation  is  detected,  the  restoration  of  a  vertex  presentation  by  a 
manual  flexion  of  the  head  presents  great  difficulty;  moreover,  the  conditions 
are  so  much  altered  by  the  change  in  shape  of  the  head  that  its  re-extension 
into  a  brow  will  almost  certainly  occur  as  soon  as  the  pains  reappear  or  the 
forceps  is  applied.     Second,  a  vertex  delivery  involves  so  extensive  a  re- 


THE   MECHANISM   OF  LABOR.  519 

moulding  of  the  head  to  its  original  shape  as  to  expose  the  child  to  great  risk 
of  danger  from  cerebral  hemorrhage ;  while  the  delivery  of  a  much-moulded 
brow  by  version — that  is,  by  the  extraction  of  the  after-coming  head — results 
in  but  little  change  in  shape,  and  is  therefore  much  the  safer  for  the  child. 
Version  is,  then,  the  only  operation  which  should  be  considered  in  these 
cases. 

The  operative  treatment  of  brow  presentations,  high,  may  be  summarized 
as  follows :  In  anterior  positions,  version  is  the  operation  of  choice.  In  the 
posterior  positions  of  unmoulded  brows  a  manual  flexion  to  au  anterior  posi- 
tion of  the  vertex  and  a  subsequent  application  of  forceps  to  the  head  should 
be  preferred ;  this  failing,  version  should  be  the  second  choice.*  In  the  pos- 
terior positions  of  much-moulded  heads  version  should  be  selected. 

A  high  application  of  forceps  to  the  brow  is  ordinarily  more  dangerous 
to  the  mother  than  a  craniotomy,  and  but  little  more  hopeful  for  the  child. 
The  abdominal  operations  would  be  indicated  only  in  the  interests  of  the 
child,  and  would  usually  be  contra-indicated  by  the  fact  that  the  vitality  of 
the  child  is  usually  considerably  lowered  by  the  time  the  ordinary  operations 
have  become  impossible. 

Management  of  Brow  Presentations  after  their  Entrance  into  the  Pelvis. — 
Since  the  brow  never  enters  the  pelvis  until  after  an  excessive  moulding 
has  been  produced,  and  since  the  adaptation  is  then  always  so  close  that  anv 
alteration  of  the  presentation  is  impossible,  it  is  unnecessary  to  discuss  in  this 
connection  any  other  problem  than  the  delivery  of  the  brow  as  such  excessively 
moulded  and  closely  adapted  to  the  pelvic  cavity. 

If  the  sinciput  is  anterior,  the  forceps  should  be  applied  to  the  sides  of  the 
head  with  the  concavity  of  its  pelvic  curve  anterior,  and  the  mechanism  of  the 
natural  delivery  of  a  persistent  brow  should  be  imitated.  The  tractions  should 
be  directed  downward  and  backward  until  the  root  of  the  nose  engages  at  the 
arch,  and  their  direction  should  then  gradually  be  moved  forward  and  upward 
until  the  occiput  sweeps  forward  over  the  perineum,  then  downward  asjaiu  to 
permit  the  emergence  of  the  face ;  but  the  chance  of  extracting  a  living 
child  in  this  way  is  so  small,  and  the  risk  to  the  mother's  tissues  is  so 
extremely  great,  that  the  application  is  never  permissible  unless  the  child 
is  in  fairly  good  condition.  If  its  vitality  is  already  seriously  lesseued,  it 
is  probably  the  best  practice  to  deliver  by  craniotomy.  Such  cases  are, 
fortunately,  almost  never  seen  during  the  life  of  the  child,  and  perhaps 
never  at  term. 

If  the  brow  has  entered  the  pelvis  with  the  sinciput  posterior,  and  the  child 
is  still  alive,  a  very  cautious  attempt  to  promote  rotation  by  the  forceps  might 
be  justifiable ;  but  success  would  be  extremely  unlikely,  and  a  resort  to  crani- 
otomy would  almost  certainly  be  necessary.  This  condition,  however,  is  so 
extremely  rare  that  it  is  almost  unnecessary  to  refer  to  it. 

*  An  extension  to  a  face  and  a  subsequent  rotation  of  the  chin  to  the  front  are  occasionally 
possible,  but  this  operation  is  always  difficult,  and  should  not  be  attempted  by  operators  of  small 
experience. 


520  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

4.  Pelvic  Presentations. 

Pelvic  presentations  are  commonly  divided  into  breech,  knee,  and  footling 
presentations ;  but  knee  and  footling  presentations  are  so  similar  in  every 
respect  to  those  of  the  whole  breech  that  it  is  convenient  to  treat  them  as  sub- 
variations. 

Frequency. — Pelvic  presentations  occur  in  about  1  in  30  labors  when  mis- 
carriages and  premature  labors  are  included.  Among  labors  at  term,  however, 
their  frequency  falls  to  about  1  in  60  cases.  Thus,  Pinard  found  among 
100,000  cases  3301  pelvic  presentations,  but  on  excluding  the  premature  cases 
the  proportion  fell  to  1  in  62.  Among  pelvic  presentations  about  60  per  cent, 
are  presentations  of  the  breech. 

Etiology. — Pelvic  presentations  are  produced  by  the  failure  of  the  condi- 
tions which  ordinarily  ensure  the  existence  of  cephalic  presentations  (see  p. 
468).  They  are,  then,  especially  frequent  among  premature  and  macerated 
children,  when  the  liquor  amnii  is  excessive  and  wdien  the  uterine  and  abdom- 
inal walls  are  very  lax.  They  are  the  rule  in  hydrocephalus,  and  one  out  of 
every  four  twins  is  a  breech  child.  In  deformed  pelves,  too,  in  which  the 
head  is  unlikely  to  become  fixed  at  the  inlet  during  the  last  weeks  of  preg- 
nancy, breech  presentations  become  more  frequent.  S.  D.  A.  and  S.  L.  P. — 
that  is,  the  two  positions  in  which  the  loug  diameter  of  the  breech  occupies 
the  first  oblique  diameter  of  the  inlet — are  much  more  common  than  S.  L.  A. 
and  S.  D.  P.  Knee  and  footling  presentations  are  probably  always  secondary, 
and  are  due  to  an  active  movement  of  the  fetal  limbs. 

Diagnosis. — On  abdominal  examination  the  head  is  found  at  the  fundus 
and  its  absence  is  noted  at  the  brim;  the  heart  is  heard  above  the  umbilicus. 
On  vaginal  examination  in  presentations  of  the  breech  the  presenting  part  is 
at  first  high  and  is  reached  with  difficulty.  The  finger  recognizes  the  vulva 
or  the  scrotum  and  penis,  as  the  case  may  be,  the  anus,  and  the  sacral  spines. 
On  rectal  examination  of  the  fetus  the  coccyx,  the  tuberosities  of  the  ilia, 
and  the  pubic  arch  are  easily  recognizable.  The  position  is  best  determined 
by  the  position  of  the  coccyx  as  ascertained  by  a  rectal  examination.  In  knee 
and  footling  cases  the  prolapsed  extremity  is  recognized  by  its  anatomical 
characters  (see  p.  465). 

Prognosis. — The  prognosis  for  the  mother  in  breech  presentations  is  only 
altered  from  the  normal  by  the  frequency  with  which  rapid  extractions  are 
necessary,  and  by  the  fact  that  in  such  extractions  there  is  a  greatly  increased 
risk  of  laceration.  The  prognosis  for  the  child  is  alwavs  poor,  the  mortality 
running  as  high  as  10  per  cent,  in  skilled  hands.  The  prognosis  for  both 
patients  is  worse  when  the  mother's  soft  parts  are  rigid — for  example,  in 
primiparse. 

Mechanism  and  Management  of  Breech  Presentations. 

Mechanism  of  Breech  Presentations. — Normal  Mechanism. — In  breech 
presentations  the  first  stage  is  ordinarily  abnormally  slow.     If  the  membranes 


THE   MECHANISM    OF   LABOR. 


52] 


are  intact,  the  dilatation  of  the  os  is  performed  by  them  as  in  head  presenta- 
tions, and  every  care  should  be  taken  to  preserve  their  integrity  until  the  os 
is  fully  dilated.  This  precaution  is  of  special  importance  in  breech  presenta- 
tions, since,  although  the  small  and  tapering  breech  is  not  ill-adapted  to  the 
dilatation  of  the  os,  the  breech,  when  considered  as  a  dilating  wedge,  labors 
under  the  disadvantage  that  its  small  size  renders  its  passage  through  the 
cervix  an  inefficient  preparation  of  the  soft  parts  for  the  passage  of  the  larger 
and  harder  head ;  extensive  lacerations  of  the  cervix  are  therefore  frequent 
whenever  the  preparation  of  the  cervix  has  been  entrusted  to  the  breech. 

When  the  resistance  of  the  cervix  has  been  overcome,  the  comparatively 
small  and  soft  breech  naturally  enters  the  pelvis  easily,  as  the  bitrochanteric 
diameter,  the  greatest  diameter  of  the  breech,  is  less  than  any  of  the  diam- 
eters of  the  brim.  The  bitrochanteric  diameter  enters  in  one  or  the  other 
oblique  diameter,  and  is  then  crowded 
downward  into  the  pelvis  until  the  pos- 
terior hip  impinges  on  the  pelvic  floor, 
when,  uuder  the  forward  shunt  of  this 
portion  of  the  posterior  wall  of  the  pel- 
vis, the  breech  as  a  whole  bends  for- 
ward by  a  lateral  inflection  of  the  trunk 
(Fig.  276).  This  movement  engages 
the  anterior  hip  in  the  deep  portion  of 
the  anterior  groove  of  that  side  of  the 
pelvis  to  which  it  is  directed,  and  as 
the  anterior  hip  rotates  forward  the 
posterior  hip  slips  back  into  the  groove 
of  the  sacrum.     The  lateral  inflection 

becomes  well  marked,  the  anterior  buttock  appears  at  the  vulva,  and  as 
the  trunk  is  driven  more  deeply  into  the  pelvis  by  the  uterine  contractions 
the  anterior  hip  becomes  fixed  at  the  pubic  arch,  and  the  posterior  hip  swings 
forward  until  the  posterior  buttock  and  trochanter  appear  successively  from 
under  the  fourchette. 

As  the  posterior  half  of  the  breech  emerges  the  perineum  retracts  upward 
along  the  child's  pelvis,  and,  all  pressure  being  thus  removed  from  the  pos- 
terior surface  of  the  breech,  the  inflection  is  released  and  the  trunk  of  the 
child  is  permitted  to  straighten  itself  again,  thus  releasing  the  anterior  hip 
from  its  position  of  pressure  against  the  pubic  arch ;  the  whole  trunk  then 
moves  downward  through  the  pelvis,  and  only  such  moderate  lateral  inflection 
as  is  necessary  to  accommodate  the  trunk  to  the  course  of  the  pelvic  bones 
still  persists.  When  the  legs  remain,  as  they  should,  in  their  normal  position 
of  flexion,  the  escape  of  the  knees  from  the  vulva  releases  the  lower  extrem- 
ities. 

At  about  the  time  the  umbilicus  appears  at  the  vulva  the  shoulders  enter 
the  brim,  their  transverse  axis  lying  in  the  oblique  diameter.  If  the  arms 
remain  in  their  normal  position — that  is,  crossed  over  the  breast — the  anterior 


Fig.  276. — Lateral  inflection  of  the  trunk  during 
expulsion  of  the  breech. 


522  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

shoulder  rotates  to  the  arch  and  is  delayed  by  fixation  against  its  inner  surface, 
while  the  posterior  shoulder  and  elbow  pass  the  vulva.  The  escape  of  the 
posterior  shoulder  so  diminishes  the  size  of  that  portion  of  the  body  occupy- 
ing the  outlet  as  to  permit  the  anterior  shoulder  to  escape  from  the  arch  and 
emerge  from  beneath  it. 

The  pressure  of  the  uterus  upon  the  longer  arm  of  the  cephalic  lever  should, 
under  normal  conditions,  preserve  the  flexion  of  the  head.  In  this  condition 
the  chin  and  the  face  necessarily  enter  the  pelvis  first,  the  suboccipito-frontal 
and  suboccipito-bregmatic  diameters  occupying  one  of  the  oblique  diameters 
of  the  superior  strait.  Since,  at  the  time  the  head  engages  at  the  superior 
strait,  the  shoulders  have  already  rotated  into  a  position  in  which  the  bis- 
acromial  diameter  occupies  the  antero-posterior  diameter  of  the  outlet,  the  head 
approaches  the  superior  strait  in  a  transverse  diameter,  but  the  recession  of  the 
posterior  portion  of  the  lateral  wall  of  the  pelvis  at  the  brim,  as  it  approaches 
the  sacro-iliac  notch,  causes  the  face  and  the  forehead,  the  first  portion  of  the 
head  entering  the  pelvis,  to  swing  backward  into  a  posterior  position.  The 
after-coming  head  thus  normally  enters  in  an  occipito-anterior  position. 

As  the  head  enters  the  excavation  the  sinciput  is  so  much  lower  in  the 
pelvis  than  the  occipital  end  of  the  head  that  it  swings  along  the  course  of 
the  posterior  groove  until  it  slips  into  the  median  Hue  upon  the  pelvic  floor, 
the  occiput  which  is  still  exposed  to  the  smooth  bony  surface  of  the  brim,  at 
the  same  time  l'otating  to  the  median  line  in  front.  The  face  appears,  followed 
by  the  forehead,  at  the  vulva,  the  perineum  retracts  over  the  bregmatic  region, 
and  the  head  is  born,  still  in  a  state  of  flexion. 

Abnormal  Mechanism  of  Breech  Presentations. — The  frequent  occurrence 
of  abnormalities  in  breech  presentations  is  to  be  accounted  for  by  the  ease 
with  which  the  legs,  the  arms,  and  the  head  may  become  extended  by  friction 
against  the  pelvic  wall.  The  descent  of  the  legs  and  the  arms  should  normally 
be  accomplished  pari  passu  with  that  of  the  body  through  the  transmission  of 
the  uterine  force  to  their  upper  surfaces  by  the  liquor  amnii ;  but  in  a  large  pro- 
portion of  cases  the  cervix  has  still  sufficient  resiliency  to  contract  tightly  upon 
the  fetal  trunk  after  the  legs  have  passed  the  cervix.  The  upper  surface  of  the 
legs  is  then  cut  off  from  the  pressure  of  the  liquor  amnii,  while  their  descent 
is  still  opposed  by  an  undiminished  friction  against  the  pelvic  walls ;  again, 
they  may  be  detained  by  being  themselves  caught  in  the  grasp  of  the  cervix, 
while  the  body  continues  to  descend  ;  or,  finally,  they  may  have  been  placed  in 
an  extended  position  by  the  action  of  their  intrinsic  muscles.  As  a  result,  it 
not  infrequently  occurs  that  the  legs  become  extended  against  the  body  during 
the  descent  of  the  breech.  Under  these  circumstances  it  occasionally  happens 
that  the  legs  are  sufficiently  closely  applied  to  the  child  to  act  as  rigid  splints 
to  its  trunk,  thus  causing  arrest  by  preventing  the  lateral  inflection  necessary 
to  the  passage  of  the  trunk.  An  arrest  due  to  this  cause  usually  necessitates  a 
resort  to  operative  interference. 

The  re-contraction  of  the  cervix  upon  the  body  may  also  result  in  an  exten- 
sion of  the  arms  upward  during  the  descent  of  the  shoulders,  until  they  lie  along 


THE  MECHANISM   OF  LABOR.  523 

the  sides  of  the  head.  The  shoulders  then  enter  the  pelvis  normally,  but 
their  further  progress  is  arrested  by  the  fact  that,  unless  the  child  be  small  or 
the  pelvis  be  unusually  ample,  the  head  and  the  arms  form  too  bulky  a  mass 
to  enter  the  pelvis  together  easily,  and  the  interference  of  the  obstetrician  is 
again  required.  Even  though  the  legs  and  the  arms  maintain  their  normal 
relations  to  the  trunk,  the  passage  of  the  head  may  be  arrested  by  extension. 
Under  normal  circumstances  the  sinciput  is  driven  into  the  pelvis,  because  the 
pressure  of  the  liquor  amnii  upon  the  forehead  is  usually  sufficient  to  overcome 
the  resistance  of  the  face  against  the  pelvic  walls,  and  there  is  nothing,  there- 
fore, to  disturb  the  original  relation  of  flexion  of  the  head  upon  the  chest ; 
but  if  the  attendant  is  injudicious  enough  to  make  traction,  or  if  the  already 
delivered  portion  of  the  trunk  is  unsupported,  its  weight,  under  the  influence 
of  gravity,  is  transmitted  to  the  head  through  the  occipito-atlantoid  articulation, 
and  a  traction  is  thus  initiated  which  is  exerted  solely  against  the  occipital  end  of 
the  head.  The  result  is  au  abnormally  rapid  descent  of  the  occiput.  If  this 
descent  occurs  before  the  head  enters  the  superior  strait,  it  may  cause  sufficient 
extension  to  result  in  the  entrance  of  the  occipito-mental  or  the  occipito-frontal 
diameter  into  the  superior  strait,  and  thus  produce  an  arrest  of  the  head  in  this 
portion  of  the  pelvis.  If  the  influence  of  gravity  only  becomes  active  after 
the  entrance  of  the  forehead  into  the  pelvis,  no  more  than  a  partial  extension 
is  likely  to  result,  but  this  partial  extension  brings  the  occiput  into  the  deeper 
portion  of  the  anterior  groove  of  one  lateral  wall,  while  the  sinciput  rests  in 
the  posterior  groove  of  the  opposite  wall.  Rotation  of  the  forehead  forward 
is  thus  prevented,  and  there  results  a  dead-lock  which  can  only  be  broken  up 
when  a  rapid  descent  of  the  forehead — that  is,  the  restoration  of  flexion — is 
secured  by  operative  influence. 

Still  another  abnormality  occasionally  occurs.  When  the  child  is  small  or 
the  pelvis  is  exceptionally  ample — in  other  words,  when  the  adaptation  between 
the  child  and  the  pelvis  is  abnormally  easy — the  shoulders  may  enter  the  brim 
in  the  transverse  diameter.  If  the  back  of  the  child  is  anterior,  this  produces 
no  modification  of  the  mechanism ;  the  shoulders  become  oblique,  and  finally 
antero-posterior,  during  their  passage  through  the  lower  part  of  the  pelvis,  the 
head  enters  with  the  sinciput  posterior,  and  the  birth  goes  on  normally.  If, 
however,  the  shoulders  enter  the  superior  strait  transversely  in  a  posterior 
position  of  the  breech,  the  face  and  the  forehead  usually  become  engaged  in  the 
anterior  portion  of  the  pelvis  before  rotation  of  the  shoulders  can  occur.  If, 
under  these  circumstances,  the  flexion  of  the  head  is  thoroughly  well  marked, 
the  forehead  passes  along  down  the  course  of  the  anterior  groove,  the  face 
appears  under  the  arch  while  the  neck  retracts  the  perineum,  and,  if  the  pains 
are  of  the  very  best,  the  forehead  may  be  urged  down  under  the  arch  and  the 
head  be  born  in  flexion. 

The  successful  conduct  of  this  form  of  mechanism  by  the  forces  of  nature 
is,  however,  rare.  It  often  happens  that  the  projecting  chin,  the  mouth,  or  the 
nose  catches  upon  the  upper  border  of  the  pubic  bones.  The  sincipital  end  of 
the  head  is  then  delayed,  extension  results,  the  head  jams  across  the  brim  by 


524  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

the  occipitomental  or  the  occipitofrontal  diameter,  and  an  absolute  arrest 
usually  follows.  Delivery  by  the  efforts  of  nature  then  almost  never  occurs, 
and  is  only  possible  when  the  adaptation  is  so  easy  that  the  uterus  is  able  to 
drive  the  occiput  through  the  brim,  while  the  chin  slips  upward  and  forward 
over  the  horizontal  ramus  of  the  pubes  in  order  to  make  room  for  it.  If  this 
happy  release  of  the  chin  happens,  complete  extension  follows,  the  occiput 
appears  under  the  fourchette,  and  the  head  is  born  in  extension.  This  move- 
ment of  extension  is,  however,  usually  accomplished  only  by  traction  on  the 
body  or  by  the  application  of  the  forceps ;  even  then  it  is  likely  to  involve  so 
much  delay  that  the  preservation  of  the  life  of  the  child  is  unlikely. 

Management  of  Breech  Presentations. — Nothing  more  thoroughly  tests 
the  skill  and  judgment  of  the  obstetrician  than  his  management  of  a  breech 
presentation.  Upon  the  one  hand,  it  is  of  the  first  importance  that  he  should 
remain  inactive  so  long  as  the  natural  jtrocesses  are  progressing  satisfactorily. 
Upon  the  other  hand,  he  must  be  prompt  to  foresee  the  appearance  of  danger 
to  the  child,  and  to  interfere  as  soon  as  this  danger  is  manifest.  He  cannot 
be  warned  too  strongly  to  avoid  premature  interference,  since  the  use  of  trac- 
tion instantly  disarranges  the  delicate  balauce  by  which  the  normal  attitude  of 
the  child  is  maintained.  As  before  stated,  the  maintenance  of  flexion  in  natu- 
ral breech  labor  is  clue  to  the  facts  that  the  legs,  arms,  and  forehead  are  driven 
down  by  the  action  of  the  intra-uterine-fluid  pressure  upon  their  upper  sur- 
faces, and  that  this  pressure  is  more  than  sufficient  to  overcome  the  friction  of 
the  pelvic  walls  against  the  lower  surfaces  of  these  parts ;  but  when  traction 
is  made  upon  the  breech,  the  additional  force  thus  supplied  is  distributed  to 
the  members  only  through  the  knees,  the  shoulders,  and  the  occipito-atlantoid 
articulation  respectively,  while  the  very  fact  of  its  application — that  is,  the 
promotion  of  a  more  rapid  descent — increases  the  force  of  friction  exerted 
against  the  feet,  the  hands,  and  the  forehead.  Traction  is  then  almost  invari- 
ably followed  by  extension  of  the  legs,  the  arms,  and  the  head,  with  all  its 
inherent  difficulties. 

AVhen,  however,  interference  is  demanded,  speed  in  extracting  the  arms 
and  head  is  essential.  After  the  scapula?  appear,  five  minutes  are  an  average 
time  within  which  the  mouth  should  be  brought  to  the  vulva. 

He  who  interferes  in  a  breech  delivery  should  feel  that  unless  unusual  good 
fortune  attends  his  efforts  he  is  likely  to  be  confronted  by  the  necessity  of  a 
manual  delivery  of  each  and  every  portion  of  the  child's  anatomy  as  these  por- 
tions successively  approach  the  pelvis.  Even  in  the  most  skilled  hands  this 
process  is  attended  by  much  more  danger  to  the  child  than  is  involved  in  a 
natural  delivery. 

Since  natural  delivery  is  ordinarily  possible  only  when  complete  flexion 
is  maintained,  since  a  single  traction  is  likely  to  produce  extension,  and  since, 
when  extension  has  once  occurred,  delivery  is  ordinarily  possible  only  by  the 
immediate  adoption  and  subsequent  prosecution  of  an  operative  extraction,  it 
becomes  evident  how  important  it  is  that  the  obstetrician  should  remain  abso- 
lutelv  inactive  unless  there  arise  circumstances  which  show  him  that  nature  is 


THE  MECHANISM   OF  LABOR.  525 

likely  to  fail — that  is,  that  the  best  chances  for  the  child  have  been  lost,  and 
that  the  second  best  must  be  taken ;  for  if  it  be  true,  upon  the  one  hand,  that 
a  prompt  natural  delivery  is  safer  for  both  mother  and  child  than  the  best 
operative  interference,  it  is  equally  true,  upon  the  other  hand,  that  when 
nature  fails  in  promptness  the  only  hope  for  the  child  and  the  best  prospect 
for  the  mother  is  to  be  secured  by  the  immediate  performance  of  an  operative 
delivery. 

Management  of  Normal  Breech  Labor. — In  breech  labor  the  obstetrician's 
duty,  so  long  as  progress  is  normally  rapid,  is  reduced  to  the  following  details  : 

It  is  wise  never  to  conduct  a  breech  labor  without  one  skilled  assistant,  if 
such  a  person  can  be  obtained.  This  assistant  should  give  the  ether  if  this  is 
required,  and  should  be  ready  to  apply  suprapubic  pressure  to  the  head  if  a 
rapid  extraction  becomes  necessary.  When  delivery  is  imminent  the  woman 
should  be  placed  in  the  lithotomy  position,  since  there  is  never  any  certainty 
that  interference  may  not  become  necessary  at  any  moment.  It  is  also  well  to 
put  the  patient  slightly  under  the  influence  of  ether  as  soon  as  the  delivery  is 
thought  to  be  near  at  hand,  since,  if  interference  is  indicated,  it  is  rendered 
greatly  easier  by  anesthesia,  and  because  a  partial  anesthesia  can  be  raised  to 
the  surgical  degree  with  much  less  loss  of  time  than  is  necessary  to  produce 
unconsciousness  in  a  totally  unetherized  patient. 

From  the  time  the  breech  enters  the  pelvis  the  fetal  heart  should  be  care- 
fully watched,  since  there  is  always  danger  of  compression  of  the  cord,  and 
for  this  reason  auy  irregularity  of  the  fetal  heart  is  sufficient  cause  for  inter- 
ference. As  soon  as  the  cord  can  be  reached  its  pulsations  will  keep  the 
obstetrician  informed  of  the  condition  of  the  child. 

As  soon  as  the  buttocks  emerge  from  the  vulva  they  should  be  wrapped  in 
a  warm  sterilized  cloth  ;*  the  attendant  should  do  his  utmost  to  relieve  the 
perineum  from  undue  strain  by  pressing  the  hips  and  the  pelvis  of  the  child 
into  close  contact  with  the  arch ;  and  even  after  the  delivery  of  the  hips  he 
should  continue  to  support  the  breech  in  an  elevated  position  for  the  same  rea- 
son. When  the  knees  appear  he  should  reduce  the  bulk  of  the  presenting  part 
by  flexing  out  the  legs.  As  soon  as  the  umbilicus  is  within  reach  of  the  finger 
he  should  gently  draw  down  a  loop  of  the  cord,  to  avoid  the  danger  of  undue 
tension  upon  the  cord  or  upon  the  umbilicus  during  the  subsequent  descent 
of  the  body.  The  hips  and  the  body  should  still  be  held  constantly  forward 
toward  the  mother's  abdomen,  in  the  curve  of  Cams,  iu  order  that  the  rota- 
tion and  expulsion  of  the  head  may  not  be  interfered  with  by  the  weight  of 
the  body;  but  no  traction  should  be  made  during  this  process.  As  the 
elbows  appear  the  forearms  should  be  drawn  out,  and  if  the  fetal  body  is 
sufficiently  elevated  the  head  should  follow  without  delay. f 

Rapid  Extraction  of  the  Breech  when  Arrested  High. — When  a  breech  is 
arrested  at  the  superior  strait  until  the  signs  of  exhaustion  of  one  or  the  other 

*  Warm  in  order  to  lessen  the  danger  of  a  premature  respiration,  sterile  on  account  of  its 
contact  with  the  vulva. 

f  For  the  procedure  of  extracting  the  head  and  arms  low,  see  page  530. 


526  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

patient  appear,  or  when  a  rapid  delivery  becomes  necessary  by  reason  of  some 
condition  which  threatens  the  life  of  mother  or  child,  five  methods  of  securing 
descent  are  applicable :  Traction  may  be  made  upon  the  anterior  groin  with 
the  finger,  the  fillet,  or  the  blunt  hook  ;  forceps  may  be  applied  to  the  breech  ; 
or  the  hand  may  be  inserted  into  the  uterus,  and  be  made  to  bring  down  a  leg 
for  use  as  a  handle  by  which  to  make  traction. 

Of  these  methods,  the  use  of  finger  iu  the  groin  is  always  preferable  when 
its  employment  is  possible,  but  iu  high  arrest  of  the  breech  the  finger  seldom 
has  sufficient  power  to  secure  descent;  and  if  the  breech  is  but  slightly 
engaged  in  the  brim  at  the  time  interference  becomes  necessary,  the  introduc- 
tion of  the  hand  to  bringdown  a  leg  is  ordinarily  the  method  which  should  be 
chosen  when  the  finger  iu  the  groin  fails.  If  the  breech  is  already  so  far 
engaged  as  to  render  this  maueuvre  difficult  or  dangerous,  the  cautious 
employment  of  the  blunt  hook  or  the  fillet  is  permissible.  An  operator  of 
practised  skill  may  succeed  by  the  forceps,  but  the  application  of  this  instru- 
ment to  the  breech  at  the  superior  strait  is  not  to  be  recommended  to  begin- 
ners. 

The  Use  of  the  Finger. — In  applying  this  method  the  half  baud  should  be 
passed  iuto  the  vagina,  the  forefinger  be  hooked  into  the  groin  in  any  manner 

convenient  to  the  operator,  and  traction 
be  made  downward  and  backward  in 
the  axis  of  the  superior  strait.  Care 
should  be  taken  to  direct  the  line  of 
traction  rather  toward  that  side  of  the 
pelvis  to  which  the  back  of  the  child 
is  directed,  in  order  to  lessen  the  dan- 
ger of  snapping  the  femur  (Fig.  277). 
The  Blunt  ^HooL— Both  the  fillet 
and  the  blunt  hook  can  usually  be  ap- 
plied to  the  groin,  without  special  diffi- 
culty, in  any  portion  of  the  pelvis,  and 

Fig.  277.— Proper  (A)  and  improper  (B)  directions       i      ,1      j?         •  i     r  •    l         a?    j.-  c 

of  traction  upon  the  thigh.*  both  furnish  fairly  effective  means  of 

traction ;  both  instruments,  however, 
labor  under  the  disadvantage  of  subjecting  the  tissues  of  the  child  to  great  risk 
of  injury,  the  blunt  hook,  when  skilfully  used,  being  perhaps  the  less  danger- 
ous. The  hook  should  be  passed,  under  the  guidance  of  the  finger,  between  the 
anterior  hip  of  the  child  and  the  pubic  bones  until  it  can  be  so  rotated  that  its 
point  passes  between  the  child's  thigh  and  abdomen.  The  finger  should  then 
be  passed  between  the  thighs  and  be  brought  into  contact  with  the  point  of  the 
hook,  which  should  then  be  settled  downward  by  gentle  traction  until  its  curve 
fits  snugly  into  the  flexure  of  the  groin.  The  shank  of  the  hook  should  then 
be  grasped  by  the  hand  to  which  the  finger  belongs  (Fig.  278),  and  traction 
should  be   made  with  the  other  hand,  the  finger  lying  in  contact  with  the 

*  Though  represented  with  the  fillet,  this  Figure  illustrates  equally  the  manner  of  employ- 
ing the  fillet,  the  blunt  hook,  or  the  finger. 


THE   MECHANISM    OF   LABOR. 


527 


point  of  the  hook  throughout  the  extraction,  in  order  to  protect  the  soft  parts 
from  injury  as  far  as  possible.  The  line  of  traction  should  be  directed  toward 
the  side  on  which  the  sacrum  lies,  in  order  to  avoid  fracture  of  the  thigh. 


Fig.  278.— Method  of  grasping  the  blunt  hook. 


The  Fillet. — The  fillet  may  be  made  of  a  piece  of  broad  tape,  preferably 
linen  on  account  of  its  greater  strength,  or  of  a  wide  strip  torn  from  a  silk 
handkerchief;  the  best  fillet  known,  however,  is  that  made  by  passing  a  stout 
cord  through  a  piece  of  rubber  tubing  about  three-eighths  of  an  inch  in 
diameter.  The  fillet  may  occasionally  be  passed  through  the  groin  by  the  un- 
aided fingers,  but  in  high  arrest  it  is  seldom  possible  to  succeed  in  adjusting  it 
by  this  method.  Several  instruments  have  been  devised  for  the  special  purpose 
of  placing  the  fillet,  but  their  place  can  be  filled  equally  well  by  a  piece  of 
string  and  a  large  English  webbing  catheter.  The  disinfected  catheter  should 
be  threaded  with  a  double  loop  of  disinfected  string  or  of  narrow  bobbin,  and 
with  its  stilette,  should  then  be  bent  to  the  shape  of  the  blunt  hook  (Fig.  279). 
The  catheter  should  be  passed  into  the 
groin  in  the  manner  directed  for  the  use 
of  the  blunt  hook,  and  the  finger  should  ■ 
draw  clown  the  projecting  loop  of  string 
until  the  end  of  the  fillet  can  be  passed 
through  it,  when,  by  the  removal  of 
the  catheter,  the  fillet  is  placed  in  posi- 
tion in  the  groin.  The  same  precaution 
as  to  the  direction  of  the  line  of  trac- 
tion must  be  observed  with  the  fillet  as 
that  recommended  for  the  blunt  hook 
and  the  finger. 

The  Use  of  Forceps. — If  the  forceps 
is  used  in  high  arrest  of  the  breech,  its 
application  is  similar  to  that  which  is  to  be  described  under  low  arrest  (p. 
528),  although   it  is  much   more  difficult. 

The  Extraction  of  a  Leg. — In  the  introduction  of  the  hand  into  the  litems 
to  bring  down  a  leg,  the  breech  should  be  pressed  back  gently  through  the 
brim  before  any  attempt  is  made  to  pass  the  hand.  The  utmost  gentleness 
should  be  observed  throughout  this  maneuvre,  and  undue  tension  on  the  utero- 
vaginal attachments  should  be  avoided  bv  a  careful  maintenance  of  counter- 


Fig.  279.— Use  of  the  catheter  as  a  porte-fillet. 


528  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

pressure  against  the  fundus  with  the  other  hand.  The  operator  should  always 
be  careful  to  ascertain  the  position  of  the  cord,  to  avoid  the  production  of  an 
unnecessary  prolapse.  If  the  foot  is  within  reach,  it  should  be  seized  and 
gently  drawn  out  from  the  os.  He  should  seize  the  anterior  leg  whenever 
that  is  accessible,  as  the  line  of  traction  on  the  anterior  leg  can  be  kept  nearly 
in  the  axis  of  the  inlet,  while  a  pull  on  the  rear  leg  brings  the  anterior  but- 
took  to  a  sitting  position  on  the  brim.  If  the  legs  are  extended  across  the 
chest,  two  fingers  should  be  placed  along  the  crest  of  the  tibia,  and  be  used 
to  so  flex  the  leg  that  the  foot  passes  down  the  median  line  of  the  child's 
abdomen  until  it  reaches  a  position  in  which  it  can  be  seized  and  with- 
drawn. 

When  the  foot  appears  at  the  vulva,  the  leg  should  be  wrapped  in  a  towel 
which  has  been  dipped  in  a  warm  solution  of  corrosive  sublimate,  and  traction 
should  be  made  upon  it  in  a  line  which  should  at  first  be  directed  as  far  back- 
ward as  the  perineum  allows,  in  order  to  pull,  so  far  as  possible,  in  the  axis  of 
the  superior  strait.  As  the  breech  descends  the  line  of  traction  should  swing 
forward,  until,  when  the  hips  clear  the  vulva,  it  is  directed  nearly  vertically 
upward,  the  woman  being  in  the  lithotomy  position.  As  soon  as  the  knee  is 
well  outside  the  vulva  the  grasp  should  be  shifted  to  the  thigh,  as  any  pro- 
longed traction  on  the  lower  leg  is  apt  to  overstrain  the  ligaments  of  the 
knee-joint,  If  there  is  any  difficulty  in  bringing  the  breech  to  the  vulva,  its 
delivery  may  be  assisted  by  hooking  the  forefinger  into  the  other  groin  as  soon 
as  it  is  within  reach  ;  as  the  breech  distends  the  perineum  it  should  be  drawn 
well  forward,  and  every  effort  should  be  made  to  prevent  a  laceration  precisely 
as  is  done  in  the  delivery  of  the  fore-coming  head. 

When  the  second  knee  appears  at  the  vulva,  it  should  be  drawn  outward 
along  the  side  of  the  child  and  toward  its  back,  until  the  fingers  can  reach  the 
leg  and  release  the  foot  by  flexiqn  of  the  leg  upon  the  thigh  ;  but  all  pressure 
upon  the  shaft  of  the  femur  must  carefully  be  avoided,  since  fracture  of  the 
femur  during  this  process  is  always  easy.  Care  should  be  taken  to  bend  the 
knee  only  in  the  natural  direction. 

Rapid  Extraction  of  the  Breech  when  Arrested  Low. — Low  arrest  of  the 
breech  can  usually  be  overcome  by  the  use  of  the  finger  in  the  groin,  which 
method  should  always  be  the  first  tried.  If  this  method  fails,  the  use  of  the 
fillet,  or,  better,  the  blunt  hook,  is  decidedly  less  dangerous  to  the  child  in  low 
than  in  high  arrest,  the  method  of  applying  them  being  exactly  the  same ;  the 
forceps  is  here,  however,  easy  and  is  almost  invariably  efficient ;  moreover,  if 
due  care  is  exercised,  this  instrument  is  far  less  likely  to  injure  the  child  than 
is  the  blunt  hook. 

Application  of  the  Forceps  to  the  Breech  Low. — If  the  breech  lies  in  an 
antero-posterior  or  oblique  position,  the  tip  of  one  blade  of  the  forceps 
should  lie  against  the  upper  sacral  vertebrae,  while  that  of  its  fellow  should  be 
pressed  into  the  flexor  surface  of  the  most  easily  accessible  thigh  (Fig.  280), 
If  the  position   of   the  hips  is  transverse,   each    tip  of  the  forceps  should 


THE   MECHANISM    OF  LABOR. 


529 


impinge  upou  a    femur  just  above    or   beyond    the    trochanter,   which    then 
furnishes  a  firm  hold  for  the  blades  (Fig.  281). 

In  making  the  application  the  forceps  should  be  placed  in  an  approxi- 
mately correct  position  upon  the  breech,  locked,  and  held  lightly  in  this  posi- 
tion. A  hand  should  then  be  passed  into  the  vagina  until  the  finger-tips  can 
touch  the  exact  spots  at  which  the  tips  of  the  blades  should  lie;  an  accurate 
adjustment  is  then  easily  attained  by  direct  movements  of  the  tips  of  the  blades 
with  the  internal  fingers.  The  small  size  of  the  tapering  breech,  in  comparison 
with  the  diameters  of  any 
pelvis  through  which  a 
living  child  can  be  ex- 
tracted, renders  it  easy  to 
obtain  an  accuracy  in  the 
adjustment  of  the  forceps 
that  is  impossible  of  at- 
tainment when  the  forceps 
is  used  upon  the  head.  It 
is  this  fact  which  renders 
the  forceps  valuable  in 
this  connection,  since  the 
avoidance  of  injury  to  the 
child  and  the  attainment 
of  a  secure  grasp  of  the 
breech  are  to  be  effected 
only  by  the  adjustment 
of  the  tips  to  exactly  the 
points  to  which  they  were 
directed,  and  the  utmost 
care  must  be  observed  in 
verifying  the  position  of 
the  forceps  before  any 
traction  is  made.  When 
the  operator  is  sure  that 
the  instrument  is  satis- 
factorily in  position,  the 
handles  should  be  grasped 
sufficiently  tight  to  ensure  a  firm  pressure,  which  should  then  be  maintained 
without  intermission  until  after  the  delivery  of  the  child. 

The  ordinary  forceps  is  better  adapted  to  this  application  than  any  special 
forms  which  have  yet  been  devised.  When  the  instrument  is  used  upon  the 
high  breech  the  advantages  of  axis-traction  are  perhaps  more  fully  apparent 
than  in  any  other  obstetric  operation. 

Rapid  Extraction  of  the  Trunk. — As  soon  as  the  legs  and  the  pelvis  of  the 
child  have  cleared  the  vulva,  they  should  be  grasped  (through  a  warm  aseptic 
towel)  in  the  manner  shown  in  Figure  282,  in  which  each  thigh  is  grasped  by 


Fig.  2S0.— Forceps  applied  to 
an  oblique  position  of  the 
breech. 


Fig.  2S1.— Forceps  applied  to 
a  transverse  position  of  the 
breech. 


530 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


-Method  of  grasping  the  thighs  during 
the  extraction  of  the  breech. 


the  fingers  of  one  hand,  the  thumbs  of  the  operator  lying  along  the  sacrum  ; 
this  grasp  should  be  maintained  throughout  the  extraction,  no  other  grasp 

being  so  secure,  and  any  pressure  upon 
the  crests  of  the  ilium  or  upon  the  ab- 
domen of  the  child  being  dangerous  to 
its  bones  and  abdominal  viscera.  The 
line  of  traction  should  be  directed  as 
far  backward  as  the  perineum  allows, 
in  order  to  facilitate  the  passage  of  the 
shoulders  through  the  superior  strait, 
and  the  back  of  the  child  should  be 
kept  steadily  directed  upward — that  is, 
toward  the  anterior  portion  of  the 
mother's  pelvis — to  secure  an  anterior 
position  of  the  occiput  for  the  after- 
coming  head.  When  the  umbilicus  ap- 
pears at  the  vulva  a  loop  of  the  cord 
should  be  drawn  downward,  as  is  done 
during  the  normal  delivery  of  the  breech. 
Rapid  Extraction  of  the  After-coming 
Head  and  Arms. — If,  by  any  chance, 
either  arm  remains  flexed  upon  the  in- 
fant's chest,  it  may  easily  be  drawn  out  when  the  elbow  appears  at  the  vulva ; 
but  in  the  great  majority  of  cases  both  arms  will  be  extended  beside  the  head, 
and  their  extraction  is  then  more  difficult.  The  method  that  should  be  chosen 
for  their  release  must  depend  upon  the  point  of  the  pelvis  at  which  the  shoul- 
ders become  arrested. 

Low  Arrest  of  the  Arms  and  tl\e  Head. — In  easy  extractions  it  is  very  often 
possible  to  bring  the  shoulders  into  sight  outside  the  vulva  by  simple  traction 
upon  the  thighs.  In  such  cases  it  is  frequently  possible  to  extract  the  after- 
coming  head  and  arms  by  the  very  easy  and  simple  maneuvre  known  as 
Deventer's  method.  In  this  procedure  the  body  of  the  child  is  dropped  down- 
ward as  soon  as  the  points  of  the  shoulders  are  in  sight ;  the  feet  are  grasped 
with  one  hand,  the  fingers  of  the  other  hand  being  pressed  upon  the  upper  sur- 
face of  the  shoulders,  and -the  child  is  drawn  vertically  downward  toward  the 
floor,  the  mother  being  in  the  lithotomy  position.  Under  this  traction  the 
occiput  appears  at  the  vulva,  and  the  forehead  and  face  follow  coincidently 
with  the  arms.  The  mechanism  by  which  this  somewhat  surprising  delivery 
is  accomplished  is  as  follows  :  The  method  is  applicable  only  wheu  the  pelvic 
space  permits  the  head  and  the  arms  to  enter  the  brim  together,  and  both  are 
then  contained  in  the  excavation  when  the  shoulders  are  at  the  vulva.  The 
arms  are  then  in  contact  with  the  elastic  sacro-sciatic  ligaments,  which  stretch 
before  them  and  permit  them  to  lie  by  the  side  of  the  head.  The  chin  is 
arrested  by  the  pelvic  floor ;  the  head  extends,  and  thus  brings  the  occiput  to 
the  vulva.     The  head  is  then  delivered  in   extension,  and  the  arms  follow 


THE   MECHANISM    OF  LABOR. 


531 


(Fig.  283).  The  original  advocates  of  this  method  claimed  that  it  rarely  if 
ever  tears  the  perineum,  and  the  writer's  experience  with  it  certainly  supports 
this  claim. 

When  the  conditions  permit  the  head  and  the  arms  to  euter  the  pelvis 
together — that  is,  when  the  shoulders  can  be  brought  to  the  vulva  by  traction 
upon  the  thighs — Deven- 
ter's  method,  though  not 
the  most  powerful,  is  cer- 
tainly by  far  the  most 
rapid  and  easy  of  all  the 
maneuvres  for  the  release  £g^ 
of  the  head  and  the  arms, 
and  it  should  always  be  j|* 
given  a  trial.  It  is  nec- 
essarily inapplicable  when 
the  head  and  the  arms 
are  arrested  at  the  superior  strait, 
tion  then  only  increases  the  difficulty. 

Combined  Traction  on  the  Face  and 
Shoulders. — If  the  shoulders  appear  at  the 
vulva,  but  Deventer's  method  fails, the  arms 
must  be  delivered  severally  before  the  head 
can  appeal-.  Two  fingers  should  be  passed 
along  the  upper  surface  of  the  most  easily 
accessible  arm  until  their  tips  rest  in  the 
bend  of  the  child's  elbow.  The  elbow  should 
then  be  urged  backward  and  toward  the  me- 
dian line  by  the  fingers,  and  be  swept  across 
the  child's  face  to  the  vulva,  at  which  the 
elbow,  forearm,  and  hand  appear  in  the 
order  named.  This  process  should  then 
be  repeated  with  the  other  arm.  Pressure 
upon  the  shaft  of  the  humerus  should  carefully  be  avoided,  since  it  is  certain 
to  suap  the  bone.  The  child  is  then  laid  astride  of  one  of  the  operator's  fore- 
arms, and  the  hand  belonging  to  this  forearm  is  passed  into  the  vagina  until 
its  first  and  second  fingers  lie  upon  the  canine  fossse  of  the  child.  The  other 
hand  is  hooked  over  the  shoulders,  the  neck  being  between  its  first  and  second 
fingers,  with  the  finger-tips  upon  the  supraclavicular  region  (Fig.  284).  The 
hand  that  is  hooked  about  the  shoulders  is  then  used  to  make  traction  upon  the 
child,  while  the  internal  hand  exerts  itself  to  preserve  the  flexion  of  the  head. 
The  direction  of  the  first  tractions  should  be  in  the  line  of  the  axis  of  that 
part  of  the  pelvis  in  which  the  child  lies,  and  as  the  head  emerges  the  line 
of  traction  should  sweep  forward  in  the  curve  of  Cams  until,  at  the  end  of  the 
extraction,  the  body  of  the  child  rests  upon  the  other  forearm  and  along  the 
abdomen  of  the  mother  (Fig.    285).     When  the  mouth  appears  at  the  vulva 


Fig.  283.— Deventer's  method  of  extraction 
of  the  after-coming  head  and  arms. 


532  AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 

and  the  mouth  and  pharynx  have  been  cleared  out,  all  hurry  ceases,  and  the 


Fig.  284.—  Delivery  of  the  after-coming  head  by  combined  traction  on  the  head  and  shoulders. 

operator's  efforts  should  be  directed  to  the  preservation  of  the  perineum.    But 

little  traction  should  now  be 
used,  aud  the  hand  that  was 
applied  to  the  face  should  be 
used  to  shell  out  the  head 
by  pressure  on  the  forehead 
through  the  perineum,  or,  if 
necessary,  by  passing  two  fin- 
gers into  the  rectum. 

High  Arrest  of  the  Arms 
and  Head. — When  the  adap- 
tation between  the  head  and 
the  pelvis  is  not  sufficiently 
easy  to  permit  the  simulta- 
neous entrance  of  the  head 
and  the  arms  into  the  pelvis, 
the  arrest  of  the  shoulders  at 
the  superior  strait  may  be 
known  by  the  fact  that  the 
child  ceases  to  make  progress, 
under  tractions  of  ordinary 
strength,  at  about  the  time 
when  the  tips  of  the  scapulre 

-Position  of  the  child  immediately  after  the  escape  -.  ,  .        ,  . 

of  the  after-coming  head  from  the  vulva.  appear  at  the  VUlva.      At  ttliS 


THE  MECHANISM   OF  LABOR.  533 

point  of  the  extraction  it  is  therefore  important  to  watch  for  a  marked  increase 
of  resistance,  and  when  this  is  observed  the  tractions  should  immediately  be 
intermitted,  since  their  continuance  only  serves  to  lock  the  head  and  the  arms 
securely  in  the  brim,  thus  rendering  the  subsequent  maneuvres  for  their  release 
more  difficult. 

The  body  of  the  child,  in  such  an  event,  should  be  pressed  slightly  upward, 
and  be  rotated  until  the  back  is  directed  to  one  or  the  other  side  of  the 
mother's  pelvis.  The  hips  should  then  be  elevated  gently  toward  the  mother's 
abdomen  and  toward  the  side  to  which  the  back  of  the  child  is  directed, 
moderate  traction  being  exerted  upon  them  at  the  same  time.  The  object  of 
this  maneuvre  is  twofold :  first,  that  space  may  be  afforded  for  the  passage 
of  the  hand  into  the  vulva  along  the  abdomen  of  the  child ;  secondly,  that  the 
posterior  shoulder,  which  is  usually  the  most  accessible,  may  be  brought  as 
deeply  into  the  pelvis  as  possible. 

The  hand  of  the  operator  that  naturally  faces  the  abdomen  of  the  child 
should  then  be  passed  rapidly  into  the  vulva,  with  its  palm  flat  against  the 
abdomen  and  chest,  until  two  fingers  can  be  passed  up  along  the  arm  of 
the  child  and  their  tips  placed  in  position  in  the  bend  of  the  elbow.  Xo 
pressure  upon  the  arm  should  be  made  until  this  position  is  reached,  but  wheu 
it  is  attained  the  elbow  should  be  drawn  down  across  the  child's  face  until 
the  forearm  and  hand  are  within  easy  reach  and  can  be  brought  to  the  vulva. 

If  the  hand  passed  along  the  abdomen  fails  to  reach  the  elbow,  the  latter 
may  sometimes  be  found  by  seizing  the  feet  in  that  hand  and  drawing  them 
gently  upward  and  to  the  opposite  side,  so  that  the  hand  which  before  held 
the  feet  can  be  passed  along  the  back  of  the  child  close  under  the  pubic  arch 
to  the  back  of  the  posterior  shoulder,  and  thence  along  the  arm  to  the  elbow, 
which,  however,  must,  as  before,  be  brought  downward  across  the  child's  face. 

The  hips  of  the  child  should  then  be  swept  downwai'd  and  traction  be  made 
upon  the  thighs,  in  the  hope  that  the  pelvic  space  may  permit  the  entrance  of 
the  head  -with  the  remaining  arm,  or  at  least  bring  the  elbow  within  the 
reach  of  the  fingers ;  if  this  does  not  occur,  the  body  of  the  child  should 
again  be  pressed  backward  into  the  pelvis,  and  the  child  be  so  rotated  that 
the  arm  which  was  anterior  becomes  posterior,  when  it  should  be  released 
by  the  same  method  that  was  used  in  the  extraction  of  the  first  arm. 
During  this  rotation  the  back  of  the  child  should  sweep  across  the  front  of  the 
mother's  pelvis.  This  rotation  may  be  effected  either  by  grasping  and  turning 
the  thorax  with  both  hands  or  by  drawing  the  already  extracted  arm  forward 
along  the  side  of  the  pelvis,  between  the  labium  and  the  back  of  the  child. 

In  rotating  the  child  it  must  always  be  remembered  that  the  articulations 
of  the  neck  are  so  arranged  that  if  the  point  of  the  chin  be  carried  beyond 
the  point  of  the  shoulder  a  dislocation  of  the  atlas  upon  the  axis  is  the  result. 
For  this  reason  the  thorax  should  be  pushed  strongly  upward  whenever  an 
attempt  at  rotation  is  made,  in  order  to  free  the  head  from  the  superior  strait ; 
and  the  hands  of  the  assistant  should  watch  the  head  from  above,  that  he  may 
warn  the  operator  if  it  fails  to  follow  the  shoulders.  In  the  extraction  of  the 
head  from  the  superior  strait  the  method  of  combined  traction  upon  face  and 


534  AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 

shoulders  is  usually  the  best,  but  it  should  then  be  reinforced  by  suprapubic 
pressure  applied  in  the  axis  of  the  brim  by  the  hands  of  an  assistant. 

Difficult  Extraction  of  the  Head  and  the  Arms. — Arrest  of  an  Arm  behind 
the  Occiput. — It  sometimes  happens  that  the  head  rotates  with  the  shoulders, 
but  the  arm  is  detained  behind  the  pubes  by  friction  against  its  walls.  In 
such  a  case  the  arm  crosses  the  nape  of  the  neck  and,  if  traction  is  made, 
becomes  jammed  between  the  occiput  and  the  symphysis.  If  this  accident  is 
discovered  before  traction  has  been  made,  prompt  rotation  in  the  reverse  direc- 
tion may  unlock  the  arm,  and  in  this  case  this  reversed  rotation  should  be 
continued  until  the  arm  becomes  posterior — that  is,  through  180°  ;  but  unless 
the  first  attempt  unlocks  the  jam,  the  child  will  probably  be  lost,  and  it  is  then, 
perhaps,  best  to  make  direct  traction  upon  the  arm  at  the  risk  of  fracturing 
the  humerus,  after  forewarning  those  present  that  this  must  be  the  result,  and 
that  it  is  done  in  the  interests  of  the  child. 

Closure,  of  a  Constriction-ring,  or  of  an  Imperfectly  dilated  Os,  about  the 
Neck. — The  stricture  of  the  canal  formed  by  either  of  these  conditions  may 
embarrass  the  release  of  the  arms,  but  it  does  not  otherwise  affect  the  above- 
described  maneuvre,  except  that  any  abrupt  or  too  forcible  movements  of  the 
hand  while  within  the  uterus  are  even  more  dangerous  in  these  cases  than  in 
others.  The  extraction  of  the  head  from  the  constricting  band  is,  however, 
often  a  matter  of  great  difficulty.  Any  attempt  to  overcome  this  obstruction 
by  force  exposes  the  mother  to  the  most  imminent  danger  of  rupture  of  the 
uterus;  and  though  steady  traction  upon  the  mouth  and  the  shoulders  should 
be  given  a  fair  trial,  and  may  effect  dilatation  in  time  to  save  the  child,  it  is  in 
these  cases  that  the  application  of  forceps  to  the  after-coming  head  is  most 
often  indicated.  There  can  be  no  doubt  of  the  truth  of  Lusk's  observation, 
that  "  the  forceps  will  sometimes  bring  the  head  rapidly  through  the  cervix 
when  traction  upon  the  feet  only  serves  to  drag  the  uterus  to  the  vulva."  Gare 
should  be  taken,  however,  that  this  rapidity  be  not  so  great  as  in  itself  to  cause 
a  serious  laceration. 

Arrest  of  the  Head,  at  the  Superior  Strait  by  reason  of  an  Unusual  Size  of 
the  Head. — Most  German  and  American  obstetricians  believe  that  the  use  of 
combined  traction  upon  the  face  and  the  shoulders  is  the  best  method  to  adopt 
in  arrest  of  the  after-coming  head  at  any  point  in  the  pelvis,  and  it  should 
certainly  be  the  first  method  tried  in  any  given  case;  but  as  cases  frequently 
occur  in  which  the  head  can  be  delivered  with  far  greater  ease  by  a  rapid  alter- 
nation between  two  or  more  methods  than  by  the  continued  use  of  any  one 
alone,  it  is  for  this  reason,  if  for  no  other,'  well  to  be  familiar  with  all  the 
methods  which  have  been  found  of  value. 

The  Prague  Method. — -This  maneuvre  is  often  of  service  in  effecting  the 
engagement  of  the  head  and  its  initial  descent  into  the  superior  strait.  This  is 
especially  true  in  certain  forms  of -contracted  pelvis  and  with  operators  whose 
muscular  strength  is  inadequate  to  the  really  severe  strain  which  is  sometimes 
imposed  upon  the  internal  hand  in  the  use  of  the  combined  method  at  the 
brim,  but  it  is  usually  inferior  to  the  combined  method  after  the  greatest  diam- 


THE   MECHANISM    OF  LABOR. 


535 


eter  of  the  head  has  passed  the'  superior  strait.  Like  all  methods  of  manual 
extraction,  it  is  greatly  increased  in  value  by  the  application  of  proper  supra- 
pubic pressure  by  an  assistant. 

In  executing  the  Prague  method  the  feet  are  seized  by  one  hand  and  the 
borlv  is  drawn  as  far  downward  as  the  perineum  allows ;  the  other  hand  is 


V 


Fig.  2S6.— Delivery  of  the  after-coming  head  by  flexion  through  seizure  of  lower  jaw,  and  extrusion  by 
means  of  pressure  in  axis  of  brim. 

then  hooked  over  the  shoulders,  and  traction  is  made  by  both  hands  simul- 
taneously (Fig.  287).  As  the  head  enters  the  excavation  the  body  is  swung 
rapidly  upward,  and  the  remainder  of  the  delivery  is  accomplished  by  upward 


Fig.  287.— Prague  method  of  extracting  the  after-coming  head,  superior  strait. 

traction  on  the  feet,  while  the  hand  upon  the  neck  promotes  flexion  by  retard- 
ing the  descent  of  the  occiput  (Fig.  288).  The  chief  disadvantage  of  the 
Prague  method  lies  in  the  fact  that  all  the  force  exerted  by  the  operator  is 
expended  upon  the  child's  neck,  and  that  the  amount  of  force  that  can  safely 
h:  applied  is  therefore  less  than  in  the  combined  method. 


536 


AMERICAN    TEXT- BOOK    OF   OBSTETRICS. 


Arrest  from  Extension  of  the  Head. — This  condition  is  rare  unless  in  im- 
properly conducted  extractions,  but  if,  by  any  clumsiness  on  the  part  of  the 

operator,  the  abdomen  of  the  child  has 
been  directed  to  the  front  during  the 
liberation  of  the  arms,  and  the  chin  is 
therefore  arrested  at  the  symphysis,  the 
Prague  method  should  be  used  through- 
out. Iu  this  case  the  direction  of  the 
first  traction  should  be  nearly  horizontal 
(Fig.  289),  and  as  the  occiput  descends 
the  body  of  the  child  should  be  raised 
until,  wheu  the  head  emerges  from  the 
vulva,  the  line  of  traction  is  nearly 
parallel  with  the  mother's  abdomen.* 

Forceps  to  the  After-coming  Head  at 
the  Superior  Strait. — The  use  of  the 
forceps  is  generally  believed  to  be  the 
most  powerful  and  certain  means  of 
overcoming  difficult  cases  of  high  arrest 
of  the  after-coming  head.  This  ope- 
ration is,  however,  often  difficult,  and 
the  time  occupied  in  the  application  of 
the  forceps  may  be  of  vital  importance 
to  the  child.  Moreover,  there  are  but 
few  cases  in  which  a  skilled  operator, 
aided  by  efficient  suprapubic  pressure, 
fails  to  deliver  by  manual  extraction  ;  but  as  such  cases  do  occasionally  occur, 
the  forceps  should  always  be  at?  hand  before  the  delivery  is  attempted.     If 


Fig.  life— Prague  method  of  extracting  the  afte 
coming  head,  inferior  strait. 


Fig.  28s.— Extraction  of  after-coming  head,  chin  arrested  at  symphysis. 


forceps  be  used,  the  body  should  be  raised  to  a  nearly  vertical  position,  and  the 

*  If  forceps  is  necessary,  the  instrument  should  be  applied  under  the  child's  body,  and  should 
extract  by  the  same  mechanism. 


THE  MECHANISM   OF  LABOR.  537 

forceps  should  be  passed  into  place  upon  the  sides  of  the  head,  beneath  the 
abdomen  of  the  child.     An  axis-traction  model  should  be  preferred. 

Arrest  of  the  Head  at  the  Inferior  Strait  or  on  the  Perineum. — Cases  in 
which  manual  extraction  by  the  combined  method  fails  to  overcome  a  low 
arrest  are  extremely  rare,  but  if  forceps  be  required  the  application  and  extrac- 
tion are  always  easy. 

Arrest  of  the  Head  due  to  Contraction  of  the  Pelvis. — In  the  ordinary  form 
of  contraction  the  arrest  is  always,  at  the  brim,  and  after  the  head  has  passed 
the  superior  strait  the  subsequent  delivery  is  easy. 

A  breech  presentation  should  never  be  allowed  to  persist  as  such  in  ajusto- 
minor  pelvis,  but  if  it  has  not  been  corrected  the  inevitable  arrest  of  the  head 
at  the  superior  strait  should  be  met  by  extreme  flexion  and  by  the  application 
of  forceps,  followed  by  craniotomy  if  not  promptly  successful. 

In  all  flat  pelves,  and  in  flat  pelves  only,  the  head  enters  the  superior  strait 
in  the  transverse  diameter,  and  the  passage  of  the  strait  is  most  easily  effected 
in  a  somewhat  extended  position,  in  which  the  biparietal  diameter  is  received 
by  one  of  the  sacro-iliac  notches,  while  the  lesser  bimastoid  diameter  is 
opposed  to  the  contracted  conjugate :  if,  then,  the  hand,  when  it  is  passed  into 
the  vagina  for  combined  traction,  finds  the  head  transverse,  it  should  allow 
extension  to  go  on  until  the  face  begins  to  approach  the  side  wall  of  the  pelvis 
or  until  the  greatest  diameter  of  the  head  has  passed  the  superior  strait;  when 
this  has  occurred  flexion  should  promptly  be  restored,  and  rotation  and  de- 
livery will  then  rapidly  follow. 

In  simple  fled  pelves  the  application  of  forceps  to  the  after-coming  head  is 
rarely  successful  after  manual  extraction  has  failed,  but  in  pelves  of  the  gen- 
erally-contracted flat  type,  if  the  transverse  diameter  is  markedly  diminished, 
the  mechanism  approaches  that  of  a  normal  or  justo-minor  pelvis,  and  if  the 
breech  presents  and  efforts  at  manual  extraction  of  the  head  fail,  the  appli- 
cation of  the  forceps  may  be  tried. 

5.  Footling  Presentations. 

Mechanism  and  Management. — The  mechanism  of  footling  presentations 
is  in  no  way  different  from  that  of  presentations  of  the  whole  breech.  The 
treatment  varies  only  in  that  in  a  rapid  extraction  there  can  be  no  question 
as  to  the  choice  of  operation. 

6.  Transverse  Presentations. 

Under  transverse  presentations  are  included  presentations  of  any  portion 
of  the  trunk ;  but  as  all  transverse  presentations  soon  change  to  presentations 
of  the  shoulder,  it  is  only  necessary  to  speak  of  the  latter. 

Frequency. — Transverse  presentations  occur  in  from  1  in  150  to  1  in  300 
of  all  cases  of  labor.  Thus,  Spiegelberg  made  the  proportion  1  in  180; 
Churchill,  1  in  252 ;  and  the  Guy's  Hospital  Reports,  1  in  297  (or  .32  per 
cent,  out  of  22,980  cases  of  labor).     The  positions  are  of  but  little  importance. 

Etiology. — Transverse  and   breech  presentations  are  produced  by  the  same 


538  AMERICAN    TEXT-BOOK   OF    OBSTETRICS. 

causes  (see  p.  520),  but  iu  transverse  presentations  the  influence  of  pelvic  de- 
formities is  somewhat  more  important,  since,  if  the  head  cannot  enter  the 
brim,  it  may  slip  to  one  side  and  permit  the  shoulder  to  enter  even  after  labor 
is  well  under  way. 

Diagnosis. — On  abdominal  examination  the  longest  diameter  of  the  uterus 
is  transverse;  the  head  is  found  in  one  flank,  and  the  breech  in  the  other.  On 
vaginal  examination  the  finger  may  be  able  to  recognize  the  clavicle  and  the 
spinous  process  of  the  scapula,  and  to  ascertain  that  there  is  but  one  limb 
attached  to  the  presenting  part,  but  the  vaginal  diagnosis  is  apt  to  be  obscure 
unless  an  arm  is  prolapsed. 

Prognosis. — As  the  termination  of  a  transverse  presentation  by  natural 
labor  is  extremely  rare,  the  prognosis  for  both  mother  and  child  is  necessarily 
that  of  the  operation  undertaken.  When  the  abnormality  is  detected  and 
treated  early,  the  prognosis  for  both  patients  should  be  fairly  good,  but  it 
becomes  worse  in  proportion  to  the  length  of  time  during  which  the  case  is 
allowed  to  go  on  untreated. 

Mechanism  and  Management  of  Transverse  Presentations. 

Mechanism  of  Transverse  Presentations. — Since  natural  delivery  so 
rarely  occurs  iu  transverse  presentations,  the  later  stages  of  the  mechanism  by 
which  it  is  effected  are  of  small  practical  importance;  but,  notwithstanding 
the  rarity  of  its  completion,  its  earlier  stages  are  rendered  not  unimportant 
by  the  fact  that  success  in  the  delivery  of  impacted  shoulders  rests  upon  a 
thorough  comprehension  of  the  processes  by  which  the  impaction  was  effected, 
this  being,  in  fact,  the  first  stage  of  the  mechanism  of  natural  delivery  in 
transverse  presentations.  The  process  is  commonly  known  as  the  "  spontaneous 
evolution  of  the  fetus."  Any  part  of  the  trunk  may  present  at  the  beginning 
of  labor;  but  as  the  fetus  is  crowded  down  into  the  brim,  the  shoulder  inev- 
itablv  enters  deepest  in  persistent  transverse  presentations,  and,  since  the  shoul- 
der always  becomes  anterior  early  in  labor,  it  is  only  necessaiy  to  describe  the 
anterior  form. 

In  the  anterior  form  the  supraclavicular  region  corresponds,  at  the  time  of 
the  entrance  of  the  shoulder,  with  the  anterior  end  of  one  oblique  diameter  at 
the  brim,  the  lower  portion  of  the  thorax  lying  at  the  posterior  end  of  the 
same  oblique  diameter.  The  full  width  of  the  shoulder  enters  the  pelvis,  and 
this  portion  of  the  child  is  then  fixed  iu  position  by  contact  of  the  neck  with 
the  horizontal  ramus  of  the  pubes.  Under  the  influence  of  the  driving  power 
of  the  uterus  above,  the  lower  portion  of  the  thorax  is  forced  more  and  more 
deeply  into  the  posterior  half  of  the  pelvis  by  a  lateral  inflection  of  the  body 
of  the  child  upon  itself.  The  trunk  then  dips  into  the  excavation,  the  true 
ribs,  false  ribs,  abdomen,  and  pelvis  of  the  fetus  entering  in  the  order  named 
(Fig.  290).  If  the  child  is  sufficiently  flexible  and  if  the  uterus  is  sufficiently 
powerful  to  complete  the  delivery,  this  process  of  lateral  inflection  of  the  trunk 
goes  on  until  the  pelvis  of  the  child  appeal's  at  the  vulva,  and  with  its  expul- 
sion the  case  is  converted   by  spontaneous  evolution  into  a  presentation,  or 


THE   MECHANISM    OF  LABOR. 


539 


rather  au  expulsion,  of  the  breech,  in  which,  however,  one  shoulder  is  already 
within  the  pelvis  and  one  arm  is  already  delivered. 

A  second  and  very  much  more  rare  form  of  delivery  in  persistent  trans- 
verse presentations  is  seen  only  with  immature  fetuses,  aud  it  can  seldom  occur 
unless  maceration  is  far  advanced.  In  it  the  prolapsed  shoulder  is  driven 
forward  through  the  pelvis,  the  head  of  the  child  being  crowded  into  the  pel- 
vis with  the  body  (Fig.  291).    The  shoulder  is  the  leading  point,  and  it  should 


290  —  Spontaneous  evolution,  first  form 


rotate  to  the  arch,  but  when  this  process  is  possible  the  body  is  always  so 
small  and  soft  that  the  mechauism  is  usually  but  little  marked. 

Management  of  Transverse  Presentations. — The  prognosis  of  sponta- 
neous evolution  is  so  bad  for  both  child  and  mother  that  transverse  presenta- 
tions should  never  be  left  to  nature,  and  the  question  of  the  treatment  is  sim- 
ply the  question  of  the  choice  of  the  operation  to  be  adopted.  Three  opera- 
tions are  applicable  to  the  treatment  of  transverse  presentations  in  its  various 
stages — the  several  varieties  of  version,  decapitation,  and  exenteration,  the  choice 
between  them  depending  upon  the  stage  of  labor  at  which  the  presentation  is 
detected. 

Version. — If  the  presentation  is  detected  before  any  portion  of  the  trunk  is 
deeply  engaged,  and  while  the  membranes  are  still  unruptured,  one  or  the 
other  of  the  external  versions  should  be  chosen.  If  the  abdomen  or  the  hip 
presents,  pelvic  version  will  usually  be  the  easiest,  aud  for  this  reason  should 
generally  be  preferred  ;  if  the  conditions  are  such  as  to  render  cephalic  version 
easy  and  if  the  pelvis  is  normal,  cephalic  version  should  be  performed. 

If  the  shoulder  presents,  cephalic  version  should  be  chosen,  except  in  a  flat 
pelvis,  where  the  shape  of  the  inlet  makes  a  breech  presentation  the  presenta- 


540 


AMERICAN   TEXT-BOOK    OF    OBSTETRICS. 


tion  of  choice.  In  such  cases  an  external  pelvic  version  would  naturally  be 
chosen.  If,  at  the  time  an  operation  is  undertaken,  the  shoulder  has  already 
entered  the  pelvis,  but  the  conditions  of  the  case  are  still  such  as  to  permit  of 
version,  a  bipolar,  cephalic,  or  pelvic  version  should  be  performed. 

If,  at  the  time  when  interference  is  decided  upon,  the    membranes   are 
already  ruptured,  and  especially  if  the  shoulder  is  already  well  crowded  into 

the  pelvis,  the  external  and  bipolar 
methods  will  usually  be  impossible,  and 
internal  podalic  version  must  be  chosen. 
Internal  Podalic  Version  in  Trans- 
verse Presentations.  —  This  operation 
differs  from  internal  version  in  head 
presentations  only  in  the  choice  and 
method  of  introducing;  the  hand,  in  the 


Fig.  291.— Spontaneous  evolution, second  and  rare 
form  of  mechanism,  known  as  birth  with  double  body 
(one-sixth  natural  size,  redrawn  from  Kiistner). 


Fig.  292.— Frozen  section  of  shoulder  presen- 
tation (Chiara):  the  distortion  and  the  elonga- 
tion of  the  neck  are  noteworthy. 


frequent   occurrence  of  a  prolapsed  arm,  and  in  the  method  of  raising  an 
impacted  shoulder. 

In  raising  the  shoulder  it  is  necessary  to  remember  the  mechanism  of  the 
method  by  which  nature  deals  with  a  neglected  transverse  presentation — that 
of  spontaneous  evolution.  In  this  process,  as  has  been  said,  the  trunk  enters 
the  pelvis  at  the  brim  in  an  oblique  diameter,  but  as  it  is  forced  farther  down 
the  shoulder  rotates  to  the  front  and  becomes  fixed  there,  while  the  thorax 
and  the  abdomen  are  crowded  into  the  posterior  portion  of  the  pelvis  by 
flexion  upon  themselves  (Fig.  290).  Now,  so  long  as  the  position  is  still 
oblique,  and  if  flexion  of  the  trunk  has  not  begun,  the  presenting  part  may 
easily  be  raised  by  pressure  upon  the  shoulder  in  the  axis  of  the  superior 
strait ;  but  so  soon  as  the  shoulder  lias  rotated  to  the  front  and  the  thorax  has 
entered  the  pelvis,  it  is  essential  that  the  process  of  relieving  the  impaction 
should  begin  by  the  return  of  the  part  which  entered  last — that  is,  of  that 
portion  of  the  thorax  and  the  abdomen  still  lying  opposite  the  sacro-iliac 
synchondrosis.  No  pressure  must  be  exerted  upon  the  shoulder  itself  until 
the  trunk  again  occupies  an  oblique  position.  It  will  be  seen  that  the  process 
of  unlocking  the  impaction  is  by  a  direct  reversal  of  the  mechanism  of  spon- 


THE  MECHANISM   OF  LABOR. 


541 


taneous  evolution.     Of  course,  during  this  whole  process  the  most  careful 
counter-pressure  must  be  maintained  at  the  fundus. 

In  simple  cases  a  prolapsed  arm  may  be  used  as  a  convenient  handle  by 
which  to  push  up  the  shoulder,  and  in  all  cases  it  is  well  to  begin  the  opera- 


Fig.  293.— Direct  method  of  seizing  a  foot  in  ver- 
sion for  transverse  presentations. 


Fig.  294.— Direct  method  of  seizing  a  foot  in  ver- 
sion for  transverse  presentations. 


tiou  by  noosing  a  fillet  around  the  prolapsed  wrist.     This  fillet  answers  a 
double  purpose:  First,  it  may  be  used  to  draw  the  arm  out  of  the  way  of  the 
operating  hand;  second,  during  the  process  of  extraction  slight  tractions  on 
the  fillet  will  prevent  the  extension  of  that    . 
arm,  thus  greatly  facilitating  the  delivery  ; 
but  care  must  be  taken  to  remove  the  noose 
as  soon  as  possible,  for  cases  are  on  record  in 
which  sloughing  of  a  member  has  followed 
the  too  prolonged  or  violent  use  of  a  fillet. 

In  the  search  for  a  foot  two  methods  may 
be  used :  The  hand  that  corresponds  with  the 
position — that  is,  left  position,  left  hand — 
may  be  passed  along  the  back  and  over  the 
buttocks  to  the  thigh  and  leg  (Fig.  295), 
or  the  hand  may  be  passed  across  the  ab- 
domen and  directly  to  the  feet  (Figs.  293, 
294).  The  first,  which  is  the  surer  way, 
should,  as  a  rule,  be  preferred,  but  the  latter 
method  is  often  the  easier,  especially  in  ab- 
domino-anterior  positions.  Much  has  been 
written  on  the  advantage  to  be  gained  by  se- 
lecting the  superior  foot  in  version  for  transverse  presentation;  but  as  this  view 
has  never  obtained  much  credence  outside  of  England,  and  asGalabin,  one  of  the 
latest  British  authorities,  not  only  disapproves  of  this  practice,  but  gives  a  very 
convincing  mechanical  proof  of  the  fallacy  of  the  theory  which  prompted  it, 


Fig.  295.— Method  of  reaching  the  foot 
by  first  passing  the  hand  around  the 
breech. 


542  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

the  subject  need  only  be  mentioned  here.     Unless  special  care  be  taken  to 
select  the  superior  foot,  the  lower  foot  is  almost  invariably  seized. 

Treatment  of  Neglected  Transverse  Presentations. — When  a  transverse  pres- 
entation has  been  so  long  neglected  that  the  release  of  the  shoulder  is  thought 
to  involve  more  danger  to  the  mother  than  it  would  be  justifiable  to  incur  in 
the  interests  of  the  child,  or  when  the  child  is  already  moribund  or  dead,  one 
or  the  other  of  the  appropriate  destructive  operations  must  be  undertaken. 

If  the  neck  is  at  this  time  within  reach,  decapitation  should  be  selected. 
If  the  process  of  spontaneous  evolution  has  gone  so  far  that  it  would  be  diffi- 
cult or  impossible  to  apply  the  decapitator  to  the  neck,  an  exenteration  should 
be  chosen,  and  after  the  abdomen  and  the  thorax  have  been  emptied  of  their 
contents  the  operator  must  use  his  judgment  as  to  whether  it  is  safer  to  break 
the  vertebral  column  and  extract  the  child  still  doubled  up  upon  itself,  or  to 
draw  the  fetal  pelvis  into  that  of  the  mother  by  traction  with  the  fingers  from 
within  its  cavity. 

7.  Prolapsed  Extremities. 

Presentation  of  the  Head  and  a  Hand. — When  a  hand  prolapses  and 
enters  the  pelvis  with  the  head,  it  is  most  commonly  placed  at  one  end  of  the 
bitemporal  diameter.  Its  presence  then  generally  results  in  delay  through  the 
increased  size  of  the  presenting  part,  and  it  may  occasionally  interfere  with 
rotation.  If  the  hand  is  placed  against  the  occipital  end  of  the  head,  its 
presence  may  delay  the  descent  of  the  occiput  and  thus  produce  extension  at 
the  brim.  This  abnormality  usually  causes  a  delay  sufficient  to  induce 
exhaustion  on  the  part  of  one  or  the  other  patient,  and  thus  indicates  opera- 
tive interference ;  but  if  such  an  indication  does  not  arise,  the  ultimate  result 
in  most  cases  is  that  the  head  slips  by  the  prolapsed  arm,  after  a  greater  or 
longer  period  of  delay,  and  is  thus  eventually  born  by  a  natural  labor. 

Prognosis. — If  the  presentation  is  detected  early,  the  prognosis  is  little  dif- 
ferent from  that  of  normal  labor,  and  even  when  detected  after  a  moderately 
long  second  stage  it  is  influenced  by  the  treatment,  and  should  never  be  grave. 

Treatment.— An  attempt  should  be  made  to  push  back  the  prolapsed  hand 
with  the  fingers,  and,  if  extension  has  occurred,  to  restore  flexion  by  pressure 
upon  the  forehead  with  the  hand.  Should  this  effort  fail,  an  operative  delivery 
must  be  resorted  to,  the  choice  of  operation  depending  upon  the  position  of 
the  head.  If  good  flexion  is  present,  the  forceps  should  be  applied,  but  care 
must  be  taken  to  introduce  the  blade  between  the  hand  and  the  head,  and 
great  care  will  be  necessary  to  avoid  fracture  of  the  fingers,  the  hand,  or  the 
wrist.  If  the  application  fails  to  do  injury,  the  prognosis  of  the  operation  is 
good,  since  the  tractile  force  is  applied  to  the  head  while  the  hand  is  still  ex- 
posed to  friction  against  the  pelvis ;  the  head  thus  always  slips  past  the  hand. 
When  marked  extension  is  present,  if  manual  flexion  fails  or  if  the  head  is 
already  much  moulded  toward  the  configuration  of  a  brow,  internal  podalic 
version  should  be  performed. 

Presentation  of  a  hand  and  a  foot  is  decidedly  more  rare  than  the 
above ;  its  prognosis  and  treatment  are,  however,  similar. 


NDEX. 


Abdomen,  hydatid  of,  in  pregnancy,  224 
Abdominal  auscultation,  460 

binder  after  labor,  433 

changes  in  pregnancy,  168 

examination  in  diagnosis  of  fetal  presenta- 
tion and  position,  406 
in  labor,  457,  461 

muscles  in  labor,  action  of,  373 

palpation  in  labor,  457 

stalk,  85 

walls  in  pregnancy,  changes  in,  152 
Abnormal  presentations,  436 
Abortion,  312 

cause  of,  313 

complete,  317 

treatment  of,  323 

diagnosis,  differential,  319 

duration  of,  314 

frequency  of,  312 

habitual  317 

incomplete,  317 

treatment  of,  323 

inevitable,  317 

treatment  of,  322 

mechanism  of,  314 

missed,  317 

treatment  of,  324 

prognosis  of,  319 

signs  of,  313 

symptoms  of,  313 

threatened,  317 

treatment  of,  322 

treatment  of,  321 

varieties  of,  317 
Accidents  and  injuries  during  pregnancy,  297 

and  surgical  operations  during  pregnancy, 
293 
After-care  of  labor,  432 
Albuminuria  in  pregnancy,  158,  221,  276 

treatment  of,  276 
Alcock's  canal,  30 
Aleeithal,  78 
Allantoic  circulation,  104 
Allantois,  85 
Amnion,  S4 

diseases  of,  300 
Amniotic  adhesions.  304 


Amniotic  bands  in  fetus,  351 
Ampullae,  68 

Amputation  of  pregnant  uterus,  295 
Anemia  in  pregnancy,  278 

treatment  of,  280 
Anesthesia  in  labor,  412 
Anesthetics  in  labor,  choice  of,  413 

method  of  administration,  413 
Antisepsis  in  labor,  391 
Appendicitis  in  pregnancy,  274 
Areola,  66 

Arteries  of  fetus,  development  of,  108 
Articulations  between  fetal  head  and  spinal 

column,  456 
Ascites  in  pregnancy,  272 
Attitude  of  fetus,  434 
Auscultation,  abdominal,  460 
focus  of,  404 

Bacteria  in  genital  tract  in  pregnancy,  213 
Bag,  obstetric,  411 

of  waters,  139.     See  also  Liquor  Amnii. 
Ballottement,  169 
Bathing  in  pregnancy,  184 
Bed,  preparation  of,  in  labor,  410 
Beginning  labor,  signs  of,  383 
Bimastoid  diameter,  453 
Binder,  abdominal,  after  labor,  433 
Biparietal  diameter,  453 
Bitemporal  diameter,  453 
Bladder,  female,  41 

in  pregnancy,  220 

functional  disturbances  of,  164 

of  fetus,  development  of,  122 
Blastodermic  stage,  95 
Blastomeres,  7S 
Blastula,  78 
Blighted  ovum,  317 
Blood-islands  of  Pander,  105 
Body,  fetal,  456 
Boiling,  sterilization  by,  393 
Brain-case,  anatomy  of,  452 
Brain  fetus,  development  of,  126 
Braxton  Hick's  sign  of  pregnancy,  169 
Breech  presentations,  520 

management  of,  524 
mechanism  of,  520 

543 


544 


Breech  presentations,  positions  of,  437 

prognosis  of,  467 
Bregma,  453 

Broad-ligament  pregnancy,  333 
Brow  presentations,  516 

management  of,  517 

mechanism  of,  516 

positions  of,  437 

prognosis  of,  467 
Bulbi  vestibuli,  38 

Canax  of  Xuck,  53 

parturient,  anatomy  of,  43S 
Cancer  in  pregnancy,  2S5 

of  uterus  in  pregnancy,  191 
treatment  of,  194 
Caput  succedaneum,  formation  of,  382 
Cardiac  disease  in  pregnancy,  280 
Carunculae  myrtiformes,  40 
Carus,  curve  of,  439,  447 
Catalepsy  in  pregnancy,  256 
Catheterization     after    labor,    cleanliness    in, 

397 
Caul,  382 
Celom,  83 

Cephalic  presentations,  frequency  of,  467 
Cerebral  hemorrhage  in  pregnancy,  250 

thrombosis  in  pregnancy,  250 
Cervical  lacerations  after  labor,  repair  of,  428 
Cervicobregmatic  diameter,  453 
Cervix,  anatomy  of,  47 

diseased,  in  pregnancy,  treatment  of, 

185 
during  labor,  changes  in,  374 

dilatation  of,  376  i 

epithelioma  of,  in  pregnancy,  194 
in  pregnancy,  changes  in,  165 
Cesarean  section  in  eclampsia,  242 
Cholera  in  fetus,  351 
in  pregnancy,  290 
treatment  of,  291 
Chorda  dorsalis,  82 

symptoms  of,  254 
treatment  of,  255 
Chorea  in  pregnancy,  252 
Chorion,  86 

diseases  of,  304 

hydatidiform  degeneration  of,  304 
cause  of,  306 

diagnosis,  differential,  307 
symptoms  of,  306 
treatment  of,  307 
myxoma  diffusum  of,  307 
fibrosum  of,  307 
Chromatin,  75 
■  'liromosomes,  75 


Circulation,  allantoic,  104 

fetal,  137 
Circulatory  system  in  fetus,  development  of, 
'  104 

in  pregnancy,  changes  in,  154 
Cleanliness  in  catheterization  after  labor,  397 

of  nurse  in  labor,  396 

of  patient  in  labor,  396 

of  the  obstetrician,  394 
Clitoris,  38 

Clothing  in  pregnancy,  184 
Coccygeus,  28 
Coitus  in  pregnancy,  184 
Colles'  fascia,  31 

Complete  abortion,  treatment  of,  323 
Conceptions,  multiple,  143 
Conduct  of  labor,  391 
Conjugate  diameter  of  pelvis,  44 
Contraction-ring  and   retraction-ring,  differen- 
tiation, 378 
Contractions,  intermittent,  in  pregnancy,  169 
Cord,  umbilical,  311.     See  also  Umbilical  Cord. 
Cranium  of  fetus,  anatomy  of,  452 
Crede's  method  of  expulsion  of  placenta,  427 
Curve  of  Cams,  439,  447 
Cystitis  in  pregnancy,  220 
Cysts  of  placenta,  309 

Death,  habitual,  of  fetus,  361 

of  fetus,  359 

diagnosis  of,  359 
Deeidua,  S7 

and  fetal  membranes,  infection  of,  in  preg- 
nancy, 205 

hypertrophy  of,  in  pregnancy,  197 
Deciduitis,  309 
Deciduoma  benignum,  319 
Deformities  and  malformations  of  fetus,  351 

of  special  regions  and  organs  of  fetus,  353 
Delivery,  face  to  pubes,  507 

in  persistently  posterior  positions,  507 

of  trunk,  424 
Descent  in  dry  labor,  mechanism  of,  481 
Diabetes  in  pregnancy,  257 
pathology  of,  259 
treatment  of,  258 
Diameter,  bimastoid.  453 

biparietal,  453 

bitemporal,  453 

cervico-bregmatie,  453 

fronto-mental,  453 

occipito-frontal,  453 

occipito-mental,  453 

suboccipito-bregmatic,  453 
Diameters  of  pelvis  and  fetal  head,  relative 
value  of,  454 


INDEX. 


545 


Diet  in  pregnancy,  183 

Digestive  system  in  fetus,  development  of,  113 
physiology  of,  141 
in  pregnancy,  changes  in,  156 
Dilatation  of  cervix  during  labor,  376 

of  os  uteri,  normal  mechanism  of,  474 
stage  of  labor,  38-5 

duration  of,  386 
management  of,  417 
mechanism  of,  473 
Disinfection  of    hands,  Furbringer's  method, 
393 
permanganate  method,  395 
practical  rules  for,  393 
Douglas's  pouch,  44,  47,  54,  151 
Dressing,  vulvar,  after  labor,  432 
Dressings,  sterilization  of,  393 
Dry  heat,  sterilization  by,  393 

labor,  mechanism  of  descent  in,  481 
Ductus  arteriosus,  138 

venosus,  137 
Duration  of  labor,  390 
of  pregnancy,  179 

Ear  of  fetus,  development  of,  133 
Eclampsia,  237 

and  epilepsy,  diagnosis,  differential,  248 

cause  of,  238 

Cesarean  section  in,  242 

disease  similar  to,  243 

mortality  from,  242 

susceptibility  to,  238 

symptoms  of,  237 

treatment  of,  240 
Ectoderm,  79 
Ectopic  pregnancy,  324.  See  also  Extra-uterine 

Pregnancy. 
Elbow  and  knee,  presentations  of,  466 
Elephantiasis  of  labia  in  pregnancy,  212 
Endometritis  in  pregnancy,  204 

treatment  of,  204 
Entoderm,  79 

Epilepsy  and  eclampsia,  diagnosis,  differential, 
248 

in  pregnancy,  24S 
Episiotomy  during  labor,  423 
Epithelioma  of  cervix  in  pregnane)',  194 
Erysipelas  in  pregnancy,  287 
treatment  of,  287 

of  fetus,  351 
Exercise  in  pregnancy,  183 
Expulsion,  mechanism  of,  4S7 

of  head,  management  of,  421 

of  placenta,  method,  Crede's,  427 

stage  of  labor,  386 

duration  of,  388 


Expulsion  stage  of  labor  in  vertex  presenta- 
tions, mechanism  of,  480 
management  of,  418 
Extra-uterine  pregnancy,  324 

after  rupture,  treatment  of,  343 

at  time  of  rupture,  treatment  of,  340 

before  rupture,  treatment  of,  339 

cause  of,  328 

diagnosis  of,  176,  336 

fetus  in,  333 

history  of,  324 

operation  in,  341 

preparation  for  operation  in,  340 

primary  forms  of,  329 

rupture  in,  335 

secondary  forms  of,  330 

symptoms  of,  334 

treatment  of,  339 
Eye  of  fetus,  development  of,  130 

Face  of  fetus,  anatomy  of,  452 
presentations,  437,  465,  508 
management  of,  512 
mechanism  of,  510 
positions  of,  437 
posterior,  mechanism  of,  512 
prognosis  of,  466 
to  pubes  delivery,  507 
Fallopian  tubes,  affections  of,  in  pregnancv. 

296 
False  knot,  312 

pelvis,  anatomy  of,  439 
Fascia?  of  pelvis,  29 

Female  and  male  pelvis,  differences  between, 
448 
bladder,  anatomy  of,  41 
generative  organs,  anatomy  of,  36 

physiology  of,  70 
ureter,  anatomy  of,  41 
urethra,  anatomy  of,  40 
Fetal  body,  anatomy  of,  456 

circulation  and  maternal  circulation,  rela- 
tion of,  140 
circulations,  137 
contour,  172 
head,  anatomy  of,  452 

and      spinal      column,     articulations 

between,  456 
dimensions  of,  453 
sutures  of,  452 
heart-sounds,  170 

membranes  and   decidua,  infection  of,  in 
pregnancy,  205 
physiology  of,  84 
movements,  169 

influence  of,  on  presentations,  471 


54G 


INDEX. 


Fetus,  amniotic  bands  in,  351 
anatomy  of,  451 
and    uterus   in   presentations,    adaptation 

between,  470 
arteries  in,  development  of,  108 
attitude  of,  434 

bladder  in,  development  of,  122 
brain  in,  development  of,  126 
changes  in  structure  of,  after  death,  360 
cholera  of,  351 

circulatory  system  in,  development  of,  104 
death  of,  359 

diagnosis  of,  359 

or  life  of,  diagnosis  of,  178 
deformities  and  malformations  in,  351 

of  special  regions  and  organs  of,  353 
determining  length  of,  104 
development  of,  74 

external  form,  95 

in  eighth  month,  102 

in  fifth  month,  102 

in  fourth  month,  102 

in  fourth  week,  96 

in  ninth  month,  102 

in  second  month,  100 

in  seventh  month,  102 

in  sixth  month,  102 

in  third  month,  101 

in  third  week,  96 

in  thirteenth  and  fourteenth  days,  95 
digestive  tract  in,  development  of,  141 

physiology  of,  141 
diseases  of,  346 
double  formations  of,  357 
ear  in,  development  of,  133  , 

erysijielas  of,  351 
excessive  development  of,  357 
eye  in,  development  of,  130 
generative  organs  in,  development  of,  122 
genito-urinary  organs  in,  development  of, 

119 
growth  of,  137 
habitual  death  of,  361 
heart  in,  development  of,  105 
in  extra-uterine  pregnancy,  333 
infections  of,  347 

kidneys  in,  before  birth,  secretion  of,  141 
life  or  death  of,  diagnosis  of,  178 
liver  in,  development  of,  119 
luxations  in,  352 
malaria  of,  350 
measles  of,  350 
metabolic  changes  in,  140 
nervous  system  in,  development  of,  126 
neural  canal  of,  development  of,  SI 
nutrition  of,  137 


Fetus,  pancreas  in,  development  of,  119 
papyraceus,  145 
physiology  of,  137 
recurrent  fever  of,  351 
respiratory  changes  in,  140 

tract  in,  development  of,  119 
salivary  glands  in,  development  of,  119 
scarlet  lever  of,  350 
septicemia  of,  350 
sex  of,  diagnosis  of,  172 
small-pox  of,  350 
special  sense  organs  in,  development  of, 

130 
spinal  cord  in,  development  of,  126 
syphilis  of,  347 

diagnosis  of,  348 
treatment  of.  349 
tuberculosis  of,  351 
tumors  of,  353 
typhoid  fever  of,  349 
veins  in,  development  of,  111 
yellow  fever  of,  351 
Fibromyomata,  1S8 
First  stage  of  labor,  385 

duration  of,  386 
management  of,  417 
mechanism  of,  473 
Flexion,  mechanism  of,  4S2 
Focus  of  auscultation,  404 
Fontanelle,  anterior,  453 

posterior  occipital,  453 
Fontanelles,  452 
Foot  and  hand,  presentation  of,  542 

presentation  of,  465 
Footling  presentations,  management  of,  537 

mechanism  of,  537 
Fore-gut,  114 

Forewaters,  139.     See  also  Liquor  Amrtii. 
Fractures  in  utero,  352 
Fronto-mental  diameter,  453 
Funic  souffle,  172 

Furbringer's  method  of  disinfection  of  hands, 
394 

Gait  in  pregnane}',  changes  in,  157 
Gartner's  duct,  62 
Gastric  ulcer  in  pregnancy,  274 
Gastrula  stage,  79 

Generative  organs,  female,  anatomy  of,  36 
physiology  of,  70 
in  fetus,  development  of,  122 
Genital  tract,  bacteria  in,  in  pregnancy,  213 
Genitals,  external,   in   pregnancy,  changes  in, 

151 
Genito-urinary  organs   in  fetus,  development 

of,  119 


INDEX 


547 


Glands  of  Bartholin,  38 
of  Montgomery,  66 
Goiter  in  pregnancy,  27S 
Gonorrhea  in  pregnancy,  282 
Gravity,  influence  of,  on  presentations,  468 

Hand  and  foot,  presentation  of,  542 
and  head,  presentation  of,  542 
presentation  of,  465 
Hands,  sterilization  of,  394 

Fiirbringer's  method,  393 
permanganate  method,  395 
Head  and  hand,  presentation  of,  542 

diameters  of,  and  diameters  of  pelvis,  rela- 
tive value  of,  454 
expulsion  of,  management  of,  421 
fetal,  anatomy  of,  452 

and   spinal  column,  articulations  be- 
tween, 456 
dimensions  of,  453 
sutures  of,  452 
Heart  of  fetus,  development  of,  105 
Heat,  dry,  sterilization  by,  393 
Hegar's  sign  of  pregnancy,  166 
Hematuria  in  pregnancy,  220 
Hemoptysis  in  pregnancy,  281 
Hemorrhage  in  pregnancy,  281 

concealed   accidental,  of  pregnancy,  225 

diagnosis  of,  226 
uterine,  in  pregnancy,  281 
Herpes  in  pregnancy,  248 
prognosis  of,  249 
treatment  of,  249 
Hind-gut,  115 

Hydatid,  abdominal,  in  pregnancy,  224 
Hvdatidiform  degeneration  of  chorion,  304 
Hydramnion,  300 

diagnosis,  differential,  302 
influence  on  labor,  303 
pathology  of,  300 
prognosis  of,  302 
symptoms  of,  302 
treatment  of,  303 
Hydrocephalus,  356 
Hydrorrhrea  gravidarum,  381 
Hygiene  of  pregnancy,  183 
Hymen,  39 
Hypertrophy  of  decidua,  197 

of  uterus,  188 
Hysterectomy  for  myomata  of  uterus,  190 
Hysteria,  influence  of  pregnancy  on,  247 
in  pregnancy,  260 

Impregnation  and  segmentation,  77 
Incomplete  abortion,  treatment  of,  323 
Inevitable  abortion,  treatment  of,  322 


Inferior  strait  of  pelvis,  442 

vena  cava,  113 
Infrapelvic  portion  of  parturient  canal,  439 

of  pelvis,  447 
Injuries  and  accidents  during  pregnancy,  297 
Instruments,  sterilization  of,  393 
Intercourse,  sexual,   in  pregnancy,  184 
Intermittent  contractions,  169 
Interpubic  disk,  23 
Interstitial  pregnancy,  332 

rupture  of  sac  in,  332 
Intervertebral  disk,  25 
Intrapelvic  signs  of  pregnancy,  164 

Jelly  of  "Wharton,  95 

Kidney  of  pregnancy,  220 
Kidneys  in  fetus,  secretion  of,  141 
Kiestein  in  pregnancy,  164 
Knee  and  elbow,  presentations  of,  466 

Labia,  elephantiasis  of,  212 
majora,  37 
minora,  37 
Labor,  368 

abdominal  binder  after,  433 

examination  in,  457,  461 

muscles  in,  action  of,  373 

palpation  in,  457 
after-care  of,  432 

and  pregnancy,  spinal  irritations  compli- 
cating, 251 
anesthesia  in,  412 
anesthetics  in,  choice  of,  413 

method  of  administration,  413 
antisepsis  in,  391 
bed  in,  preparation  of,  410 
beginning,  signs  of,  383 
catheterization  after,  cleanliness  in,  397 
cause  of,  36S 

cervical  lacerations  after,  repair  of,  428 
cervix  during,  changes  in,  374 
dilatation  of,  376 
classification  of,  436 
cleanliness  of  hands  during,  394 

of  nurse  during,  396 

of  patient  during,  396 
conduct  of,  391 
course  of,  383 
date  of,  prediction  of,  181 
delivery  of  trunk  in,  424 
diagnosis  of,  457 

frequency  and  prognosis  of,  457 
dilatation  stage  of,  385 

duration  of,  386 
management  of,  417 


548 


INDEX. 


Labor,  dilatation  stage  of,  mechanism  of,  473 
disinfection  in,  393 
dry,  481 

descent  in,  mechanism  of,  481 
duration  of,  390 
episiotomy  during,  423 
examination  during,  415 
expulsion  of  head  in,  management  of,  121 
stage  of,  38b' 

duration  of,  388 
management  of,  418 
in  vertex  presentations,  mechan- 
ism of,  480 
external  measurements  of  pelvis  in,  407 
first  stage  of,  385 

duration  of,  386 
management  of,  417 
mechanism  of,  473 
influence  of  hydramnion  on,  303 
lacerations  after,  repair  of,  428 

of  pelvic  floor  after,  429 
ligaments  in  action  of,  373 
location  of  orifice  in,  377 
lower  uterine  segment  in,  changes  in,  377 

thickness  of,  379 
lying-in  room  in,  409 
management  of,  398 
of  cord  in,  424 
mechanism  of,  434 
nurse's  preparation  in,  409 
obstetric  bag  in,  411 

examination  in,  399 
position  in,  418 
pains,  371 

amount  of  force  exerted  by,  373 
change  in  shape  of  uterus  during,  373 
Ideation  of,  372 
patient  after,  toilet  of,  432 
in,  preparation  of,  411 
pelvic  floor  during,  changes  in,  388 

prevention  of  injuries  to,  419 
physiology  of,  368 
placental  stage  of,  390 

duration  of,  390 
management  of,  426,  492 
mechanism  of,  490 
position  during,  418 
rupture  of  membranes  during,  418 
second  stage  of,  3S6 

duration  of,  388 

in  vertex  presentations,  mechan- 
ism of,  480 
management  of,  418 
stages  of,  385 
third  stage  of,  390 

duration  of,  390 


Labor,  third  stage  of,  management  of,  426,  492 
mechanism  of,  490 
uterus  during,  changes  in,  379 
vagina  during,  action  of,  374 
vaginal  examination  in,  408,  461 

frequency  of,  419 
vulvar  dressing  after,  432 
Lacerations  after  labor,  repair  of,  418 
cervical,  after  labor,  repair  of,  428 
of  pelvic  floor  after  labor,  429 
Lactiferous  duct,  67 
Levator  ani,  importance  of,  27 
Ligaments  in  labor,  action  of,  373 
Ligation  of  umbilical  cord,  425 
Liquor  amnii,  139 

character  of,  382 
variations  in,  304 
Lithopedion,  334 
Liver,  atrophy  of,  in  pregnancy,  273 

of  fetus,  development  of,  119 
Longitudinal  presentations,  436 
Luxations  in  fetus,  352 
Lying-in  room,  409 

Malaria  of  fetus,  350 

Male  and  female  pelvis,  differences  between 
448 

pronucleus,  77 
Mamma?,  anatomy  of,  65 

blood-vessels  of,  69 

nerves  of,  70 

size  of,  65 
Mammary  changes  during  pregnancy,  163 

glands  in  pregnancy,  changes  in,  152 
treatment  of,  1S7 
Mammillae,  65 
Mania  in  pregnancy,  260 
treatment  of,  261 
Maternal    circulation    and    fetal    circulation, 
relation  of,  140 

impressions,  251,  357 

organs,  changes  in,  in  pregnancy,  146 
Measles  in  pregnane}',  288 

t  of  fetus,  350 
Meconium,  142 
Meningitis  in  pregnancy,  251 
Menstruation,  physiology  of,  72 

stages  of,  72 

suppression  of,  in  pregnancy,  162 
Mental  condition  of  pregnancy,  173,  185 
Mesoderm,  80 
Mid-gut,  115 
Miscarriage,  312 
Missed  abortion,  317 

treatment  of,  324 
Moles,  tubal,  331 


INDEX. 


549 


Mons  veneris,  37 
Morning  sickness,  101 
Morula,  7S 

Mouth  and  teeth,  diseases  of,  in  pregnancy, 
277 

treatment  of,  277 
Mulberry  mass,  78 
Mullerian  ducts,  12L 
Mailer's  ring,  149 
Multiple  conceptions,  143 

pregnancy,  diagnosis  of,  177 
Muscles,  abdominal,  in  labor,  action  of,  373 
Myomata  of  uterus  in  pregnancy,  188 

hysterectomy  for,  190 

treatment  of,  190 
Myomatous  tumors,  influence  upon  pregnancy, 

294 
Myomectomy  during  pregnancy,  294 
Myomotomy  during  pregnancy,  294 

Natural  presentations,  436 
Nausea   and   vomiting   in  diagnosis   of  preg- 
nancy, 161 
of  pregnancy,  261 
diagnosis  of,  262 
treatment  of,  266 
Nervous  system,  changes  in,  in  pregnancy,  160 
development  of,  in  fetus,  126 
disorders  of,  in  pregnancy,  245 
poisonings  of,  in  pregnancy,  257 
Neuralgia  in  pregnancy,  245 
Normal  presentations,  436 
Nurse,  cleanliness  of,  in  labor,  396 

preparation  of,  in  labor,  409 
Nutrition,  changes  in,  in  pregnancy,  156 

Oblique  diameters  of  pelvis,  442 
Obstetric  antisepsis,  394 

bag,  411 

diameter  of  pelvis,  442 

examination  in  labor,  399 

position  in  labor,  418 
Obstetrician,  cleanliness  of,  394 
Occipito-frontal  diameter,  453 
Occipito-mental  diameter,  453 
Oligohydramnios,  303 
Os  uteri,  dilatation  of,  normal  mechanism  of, 

474 
Osseous  elements   in  pregnancy,   changes  in, 

157 
Otic  pit,  133 

vesicles,  133 
Ovarian  tumors  in  pregnancy,  208 
Ovaries,  57 

Ovariotomy  in  pregnancy,  208 
Ovary,  diseased,  in  pregnancy,  206 


Ovary,  diseased,  in  pregnancy,  treatment  of,  207 

tumors  of,  in  pregnancy,  295 
Oviducts,  56 
( Ivulation,  70 
Ovum,  blighted,  317 

diseases  of,  in  pregnancy,  300 

fertilization  of,  74,  77,  180 

maturation  of,  74 

segmentation  of,  77 

Pains  of  labor,  371 

amount  of  force  exerted  by,  373 
change  in  shape  of  uterus  during,  373 
location  of,  372 
Palpation,  abdominal,  in  labor,  457 

differential  diagnosis  of  presentation  by, 

459 
in  diagnosis  of  breech  presentations,  459 
of  position,  459 
of  presentation,  458 
of  transverse  presentations,  459 
Pancreas  of  fetus,  development  of,  119 
Paroophoron,  62 
Parovarium,  62 

Parturient  canal,  anatomy  of,  438 
Patient  after  labor,  toilet  of,  432 
cleanliness  of,  in  labor,  396 
preparation  of,  in  labor,  411 
Pelvic  floor,  anatomy  of,  30 

changes  in,  in  labor,  388 

in  pregnancy,  152 
lacerations  of,  after  labor,  429 
prevention  of  injuries  to,  in  labor,  419 
ligaments,    relaxation    of,    in    pregnancy, 

228 

peritoneum,  changes  in,  in  pregnancy,  150 

Pelvimeter,  Schultze's,  411 

Pelvis,  anatomy  of,  17,  438 

articulations  of,  22 

changes  in,  in  pregnancy,  151 
conjugate  diameter  of,  442 
diameter  of,  and  diameters  of  fetal  head, 

relative  value  of,  454 
dimensions  of,  20 
excavation  of,  440,  444 
external  measurement  of,  in  labor,  408 
fasciae  of,  29 

in  pregnancy,  examination  of,  186 
male  and  female,  differences  between,  448 
oblique  diameters  of,  442 
obstetrical  diameter  of,  442 
position  of,  20 

transverse  diameters  of,  442,  444 
Peptonuria  in  pregnancy,  276 

treatment  of,  276 
Peritonitis  in  pregnancy,  224 


550 


INDEX. 


Permanganate  method  of  sterilizing  the  hands, 

395 
Placenta,  87 

anomalies  of,  307 

calcareous  deposits  in,  308 

cysts  of,  309 

edema  of,  308 

expulsion  of,  Crede's  method,  427 

fatty  degeneration  of,  308 

fibrous  degeneration  of,  308 

inflammation  of,  308 

myxomatous  degeneration  of,  308 

structure  of,  91 

syphilis  of,  309 

tuberculosis  of,  310 

tumors  of,  309 
Placental  apoplexies,  310 

circulation,  139 

infarcts,  310 

marginata,  310 

souffle,  461 

stage  of  labor,  390 

duration  of,  390 
management  of,  426,  492 
mechanism  of,  490 
Plethora,  loo 

Pneumonia  in  pregnancy,  289 
prognosis  of,  290 
treatment  of,  290 
Polyneuritis  in  pregnancy,  247 
Position  and  presentation,  diagnosis  of,  400 

definition  of,  436 

diagnosis  of,  by  palpation,  459 

persistently  posterior,  delivery  in,  507 
Pouch  of  Douglas,  44,  47,  54 
Pregnancy,  74 

abdominal,  changes  in,  168 
examination  in,  186 
walls  in,  changes  in,  152 

accidents  and  injuries  during,  297 

and  surgical  operations  during,  293 

acute  infections  in,  282 

albuminuria  in,  158,  221,  276 
treatment  of,  276 

and  labor,  spinal  irritations  in,  251 

anemia  in,  278 

treatment  of,  280 

appendicitis  in,  274 

articulations  of  pelvis  in,  changes  in,  151 

ascites  in,  272 

atrophy  of  liver  in,  273 

bathing  in,  184 

bladder  in,  functional  disturbances  of,  164 

cancer  in,  285 

cardiac  disease  in,  280 

catalepsy  in,  256 


Pregnancy,  cerebral  hemorrhage  in,  250 
thrombosis  in,  250 
cervix  in,  changes  in,  165 
cholera  in,  290 

prognosis  of,  291 
treatment  of,  291 
chorea  in,  252 

symptoms  of,  254 
treatment  of,  255 
circulator}'  system  in,  changes  in,  154 
clothing  in,  184 
coitus  in,  184 
cystitis  in,  220 
death  during,  249 
diabetes  in,  257 

pathology  of,  259 
treatment  of,  258 
diagnosis  of,  161 

differential,  174 
nausea  and  vomiting  in,  161 
diet  in,  183 

digestive  system  in,  changes  in,  156 
duration  of,  179 

eclampsia  in,  237.     See  Eclampsia. 
endometritis  in,  204 

treatment  of,  204 
epilepsy  in,  248 

and  eclampsia  in,  diagnosis,  differen- 
tial, 248 
erysipelas  in,  287 

treatment  of,  287 
exercise  in,  183 
extra-uterine,  324 

after  rupture,  treatment  of,  343 
at  time  of  rupture,  treatment  of, 

340 
before  rupture,  treatment  of,  339 
cause  of,  328 
diagnosis  of,  176,  336 

evacuation  of  an  extraperitoneal 

gestation-sac  in,  345 
fetus  in,  333 
history  of,  324 
operation  in,  341 
preparation  for,  340 
primary  forms  of,  329 
secondary  forms  of,  330 
symptoms  of,  334 
treatment  of,  339 
vaginal     opening   and    drainage 
in,  344 
gait  in,  changes  in,  157 
gastric  ulcer  in,  274 
general  changes  in,  154 
genitals,  external,  in,  changes  in,  151 
goiter  in,  278 


INDEX. 


551 


Pregnancy,  gonorrhea  in,  282 
Hegar's  sign  of,  160 
hematuria  in,  220 
hemoptysis  in,  281 
hemorrhage  of,  225 

diagnosis  of,  226 
herpes  in,  248 

prognosis  of,  249 
treatment  of,  249 
hygiene  of,  183 
hysteria  in,  260 
infections,  acute,  in,  282 
injuries  and  accidents  in,  297 
intermittent  contractions  in,  169 
interstitial,  332 
intrapelvic  signs  of,  164 
kidneys  during,  220 
kiestein  in,  1(34 

mammary  changes  during,  163 
glands  in,  changes  in,  152 

treatment  of,  187 
management  of,  186 
mania  in,  260 

treatment  of,  261 
maternal  impressions  in,  251 

organs  in,  changes  in,  146 
measles  in,  288 
meningitis  in,  251 

menstruation  in,  suppression  of,  162 
mental  condition  of,  173,  185 
mouth  and  teeth  in,  diseases  of,  277 

treatment  of,  277 
multiple,  diagnosis  of,  177 
myomatous  tumors  in,  influence  on,  294 
myomectomy  in,  294 
myomotomy  in,  294 
nausea  and  vomiting  of,  261 

diagnosis  of,  262 

treatment  of,  266 
nervous  system  in,  changes  in,  160 

disorder's  of,  245 

poisonings  of,  257 
neuralgia  in,  245 
nutrition  in,  changes  in,  156 
osseous  elements  in,  changes  in,  157 
ovariotomy  in,  208 
pathology  of,  188 
pelvic  floor  in,  changes  in,  152 
pelvis  in,  examination  of,  186 
peptonuria  in,  276 

treatment  of,  276 
peritonitis  in,  224 
physiology  of,  74 
pneumonia  in,  289 
prognosis  of,  290 
treatment  of,  290 


Pregnancy,  polyneuritis  in,  247 
posture  and  bearing  of,  228 
prior,  diagnosis  of,  177 
prolongation  of,  181 
pruritus  in,  259 
purpura  hemorrhagica  in,  279 
reflex  excitability  in,  247 
renal  functions  in,  care  of,  186 
respiration  in,  changes  in,  156 
rest  in,  184 
salivation  in,  248 
salpingitis  in,  206 
scarlatina  in,  289 
signs  of,  161 
skin  in,  changes  in,  157 
smallpox  in,  289 
stomach  disorder  in,  care  of,  186 
surgical  operations  and  accidents  during, 

293 
symptoms  and  signs  of,  161 

value  of,  174 
syphilitic  infection  in,  284 
tetanus  in,  291 

treatment  of,  291 
tetany  in,  292 

treatment  of,  293 
toxemia  of,  228 

diagnosis  of,  235 

prevention  of,  233 

treatment  of,  235 
tubal,  330 
tubo-uterine,  -332 
typhoid  fever  during,  2S6 
diagnosis  of,  287 
umbilicus  in,  changes  in,  152 
urea  in,  232 
uremia  in,  160 
urethra  in,  220 
urinary  organs  in,  disorders  of,  220 

treatment  of,  223 
urine  in,  changes  in,  157 

toxicity  of,  232 
uterus  and  peritoneum  in,  relations  of,  150 

in,  changed  position  of,  167 

changes  in,  146 
vagina  in,  changes  in,  151 
vaginal  mucous  membrane  in,  changes  in, 

166 
vomiting  and  nausea  in  diagnosis  of,  161 
diagnosis  of,  262 
treatment  of,  266 
vulvar  mucous  membrane  in,  changes  in, 

166,  168 
weight  in,  increase  in,  156 
Presentation  and  position,  diagnosis  of,  400 
definition  of,  435 


5o2 


INDEX. 


Presentation,  diagnosis  of,  by  palpation,  458 

differentia],  by  palpation,  459 
examination  of  lower  fetal  pole  in,  401 

of  upper  fetal  pole  in,  402,  404 
fetal,  and  position,  diagnosis  of,  400 
location  of  cephalic  prominence  in,  403 

of  fetal  heart-tones  in,  404 

of  the  dorsal  plane  and  small  parts 
in,  400 
of  a  hand  and  a  foot,  542 

or  a  foot,  465 
of  the  head  and  a  hand,  542 
Presentations,  436 
abnormal,  430 
adaptation  between  fetus  and    uterus  in, 

470 
breech,  520 

diagnosis  by  palpation,  459 

management  of,  524 

mechanism  of,  520 

positions  of,  437 

prognosis  of,  467 
brow,  516 

management  of,  517 

mechanism  of,  516 

positions  of,  437 

prognosis  of,  467 
causes  of,  468 
cephalic,  frequency  of,  467 
face,  508 

mechanism  of,  510 

positions  of,  437 

posterior,  mechanism  of,  512 

prognosis  of,  466 
footling,  management  of,  537  f 

mechanism  of,  537 
frequency  of,  466 
influence  of  fetal  movements  on,  471 

of  gravity  on,  468 
longitudinal,  436 
natural,  436 
normal,  436 

of  elbow  and  knee,  466 
positions  of,  437 

posterior  face,  mechanism  of,  512 
signs  of,  464 
transverse,  537 

diagnosis  by  palpation,  459 

management  of,  539 

mechanism  of,  538 

positions  of,  437 

prognosis  of,  467 
unnatural,  436 
vertex,  467 

left  posterior  positions  in,  mechanism 
of,  499 


Presentations,    vertex,    location     of    anterior 
shoulder  in,  403 
positions  of,  437 
posterior  positions  in,  management  of, 

499 
prognosis  of,  466 
right  posterior  positions  in,  median. 

ism  of,  492 
second  stage  of  labor  in,  mechanism 
of,  480 
Prior  pregnancy,  diagnosis  of,  177 
Prolongation  of  pregnancy,  181 
Pruritus  in  pregnancy,  259 
Pseudocyesis,  272 
diagnosis  of,  273 
treatment  of,  273 
Psychical  amenorrhea,  163 
Puerperal  osteophytes,  157 
Purpura  hemorrhagica  in  pregnancy,  279 

QTJICKENrjSG,  169 

when  first  noticed,  181 

Rauber's  cells,  79 

Recurrent  fever  of  fetus,  351 

Reflex  excitability  in  pregnancy,  247 

Respiration,  changes  in,  in  pregnancy,  156 

Respiratory  changes  in  fetus,  140 

tract  in  fetus,  development  of,  119 
Rest  in  pregnancy,  184 

Retraction-ring  and  contraction-ring,  differen- 
tiation, 378 
Retroversion  of  gravid  uterus,  215 
Rotation,  mechanism  of,  4S5 
Rupture  of  extra-uterine  pregnancy,  335 

of  membranes  during  labor,  418 

of  sac  in  tubo-uterine  pregnancy,  332 

of  uterus  in  pregnancy,  197 

treatment  of,  200,  204 

tubal,  332 

Salivary   glands   in   fetus,  development   of, 

119 
Salivation  in  pregnancy,  248 
Salpingitis  in  pregnancy,  206 
Scarlatina  in  pregnancy,  289 
Scarlet  fever  of  fetus,  350 
Schultze's  pelvimeter,  411 
Second  stage  of  labor,  386 

duration  of,  388 
management  of,  418 
vertex  presentations,  mechanism 
of,  480 
Segmentation  and  impregnation,  77 
nucleus,  77 
physiology  of,  77 


INDEX. 


553 


Septicemia  of  fetus,  350 
Sexual  intercourse  in  pregnancy,  184 
Show,  384 

Signs  and  symptoms  of  pregnancy,  161 
value  of,  174 

of  beginning  labor,  383 
Skin  in  pregnancy,  changes  in,  157 
Smallpox  in  pregnancy,  2S9 

of  fetus,  350 
Somatopleure,  83 
Somites,  82 
Souffle,  uterine,  461 
Space  of  Ketzius,  30 
Spermatids,  76 
Sperm-nucleus,  77 
Spina  bifida,  356 

Spinal   column  and    fetal   head,   articulation 
between,  456 

cord  of  fetus,  development  of,  130 

irritations  in  pregnancy  and  labor,  251 
Splanchnopleure,  83 
Sterilization  by  boiling,  393 

by  dry  heat,  393 

by  steam,  393 

of  the  hands,  394 

permanganate  method,  395 
Stomach  disorder  iu  pregnancy,  care  of,  186 
Strise  gravidarum,  152 
Suboecipito-bregmatic  diameter,  453 
Superfetation,  145 
Superimpregmtion,  145 

Surgical  operations  and  accidents  during  preg- 
nancy, 293 
Sutures  of  fetal  head,  452 
Symphysis  pubis,  22  i 

Symptoms  and  signs  of  pregnancy,  161 

value  of,  174 
Syncytium,  91 
Syphilis,  fetal,  347 

diagnosis  of,  34S 
treatment  of,  349 

of  placenta,  309 
Syphilitic  infection  in  pregnancy,  2S4  ' 

TETA2frs  in  pregnancy,  291 

treatment  of,  291 

Tetany  in  pregnancy,  292 

treatment  of,  293 

Third  stage  of  labor,  390 

duration  of,  390 
management  of,  426,  492 
mechanism  of,  490 
Threatened  abortion,  treatment  of,  322  . 
Toilet  of  patient  after  labor,  432 
Toxemia  of  pregnancy,  228 
diagnosis  of,  235 


Toxemia  of  pregnancy,  prevention  of,  233 

treatment  of,  235 
Toxicity  of  urine  in  pregnancy,  232 
Transverse  diameters  of  pelvis,  442,  444 
presentations,  537 

management  of,  539 
mechanism  of,  538 
positions  of,  437 
prognosis  of,  467 
Trophoblast,  90 
Trunk,  delivery  of,  424 
of  fetal  body,  457 
Tubal  abortion,  332 
moles,  331 
pregnancy,  330 
rupture,  332 
Tuberculosis  of  fetus,  351 
Tubo-uterine  pregnancy,  332 
Tumors,     myomatous,     influence   upon   preg- 
nancy, 294 
of  fetus,  353 
of  placenta,  309 
ovarian,  in  pregnancy,  208,  295 
Typhoid  fever  during  pregnancy,  286 
diagnosis  of,  287 
of  fetus,  349 

Ulcer,  gastric,  in  pregnancy,  274 
Umbilical  cord,  311 

anomalies  of,  311 
constituents  of,  94 
convolutions  of,  311 
dimensions  of,  94 
hernia  of,  312 
knots  of,  312 
ligation  of,  425 
management  of,  424 
physiology  of,  94 
structure  of,  95 
swellings  of,  312 
torsion  of,  311 
vessels  of,  changes  in,  312 
souffle,  172 
Umbilicus,  changes  in,  in  pregnancy,  152 
Urachus,  122 
Uremia  in  pregnancy,  160 
Urethra  in  pregnancy,  220 
Urinary  organs  in  pregnancy,  222 

disorders  of,  treatment  of,  223 
Urine,  changes  in,  in  pregnancy,  1 57 

toxicity  of,  in  pregnancy,  232 
Uterine  contents,  premature  expulsion  of,  312 
fibroids,  188 

segment,  lower,  changes  in,  in  labor,  377 
souffle,  170,  461 
Utero-gestation,  periods  of,  173 


554 


IXDEX. 


Uterus,  amputation  of,  in  pregnancy,  295 
anatomy  of,  45 
and  appendages,    pathological    conditions 

of,  188 
and  fetus  in   presentations,  adaptation  be- 
tween, 470 
and   peritoneum    in    pregnancy,  relations 

of,  150 
cancer  of,  in  pregnancy,  191 

treatment  of,  194 
change  in  position  of,  in  pregnancy,  167 
changes  in,  in  pregnancy,  140 
during  labor,  changes  in,  379 

pains,  changes  in  shape  of,  373 
dimensions  of,  46 

displacements  of,  in  pregnancy,  215 
hemorrhage  from,  in  pregnancy,  281 
hypertrophy  of,  1S8 
ligaments  of,  51 
myouiata  of,  in  pregnancy,  188 

treatment  of,  190 
normal  position  of,  54 
retroversion  of,  in  pregnancy,  215 

treatment  of,  215 
rupture  of,  in  pregnancy,  197 

treatment  of,  200,  204 
walls  of,  structure  of,  49 

Vagina,  action  of,  in  labor,  373 
anatomy  of,  42 
changes  in,  in  pregnancy,  151 
diseased  states  of,  in  pregnancy,  214 
examination  of,  in  labor,  408 


Vagina,  examination  of,   in  labor,   frequency 
of,  419 
in  diagnosis  of  labor,  461 
Vaginal    mucous     membrane    in    pregnancy, 

changes  in,  166,  168 
Vertex  presentations,  467 

left  posterior  positions  in  mechanism 

of,  499 
location  of  anterior  shoulder  in,  403 
positions  of,  437 
posterior    positions   in,    management 

of,  499 
prognosis  of,  466 

right  posterior  positions  in,  mechan- 
ism of,  492 
second  stage  of  labor  in,  mechanism 
of,  480 
Vestibule,  38 

Vitelline  circulation,  104,  139 
Vomiting  and  nausea  in  diagnosis  of  pregnancy, 
161 
of  pregnancy,  261 
diagnosis  of,  262 
treatment  of,  266 
Vulva  disorders  of,  in  pregnancy,  212 
Vulvar  dressing  after  labor,  432 

Waters,  bag  of,  380 
Weight  in  pregnancy,  increase  in,  156 
Wolffian  bodies,  120 
duct,  119 

Yellow  fever  of  fetus,  351 


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which  alone  is  sufficient  to  place  you  first  in  the  ranks  of  medical  publishers." 

Matthew  D.  Mann,  M.  D., 

Professor  of  Obstetrics  and  Gynecology  in  the  University  of  Buffalo. 

"  I   like   it  exceedingly  and  have  recommended   the  first  volume  as  a  text-book  for  our 
sophomore  class.     It  is  certainly  a  most  excellent  work.     I  know  of  none  better." 

American  Journal  of  the  Medical  Sciences 

"  As  an  authority,  as  a  book  of  reference,  as  a  '  working  book  '  for  the  student  or  practi- 
tioner, we  commend  it  because  we  believe  there  is  no  better." 


SAUNDERS'    BOOKS   ON 


Dorland's 
Modern   Obstetrics 


Modern  Obstetrics:  General  and  Operative.     By  W.  A.  Newman 

Dorland,  A.  M.,  M.  D.,  Assistant  Demonstrator  of  Obstetrics,  Univer- 
sity of  Pennsylvania ;  Associate  in  Gynecology  in  the  Philadelphia 
Polyclinic.  Handsome  octavo  volume  of  797  pages,  with  201  illustra- 
tions.    Cloth,  $4.00  net. 

Second  Edition,  Revised  and  Greatly  Enlarged 

In  this  edition  the  book  has  been  entirely  rewritten  and  very  greatly  enlarged. 
Among  the  new  subjects  introduced  are  the  surgical  treatment  of  puerperal  sepsis, 
infant  mortality,  placental  transmission  of  diseases,  serum-therapy  of  puerperal 
sepsis,  etc.  By  new  illustrations  the  text  has  been  elucidated,  and  the  subject  pre- 
sented in  a  most  instructive  and  acceptable  form. 

Journal  of  the  American  Medical  Association 

"  This  work  deserves  commendation,  and  that  it  has  received  what  it  deserves  at  the  hands 
of  the  profession  is  attested  by  the  fact  that  a  second  edition  is  called  for  within  such  a  short 
time.     Especially  deserving  of  praise  is  the  chapter  on  puerperal  sepsis." 

Davis'  Obstetric  and 
Gynecologic  Nursing 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Davis,  A.  M., 
M.  D.,  Professor  of  Obstetrics  in  the  Jefferson  Medical  College  and 
Philadelphia  Polyclinic ;  Obstetrician  and  Gynecologist,  Philadelphia 
Hospital.      i2mo  of  400  pages,  illustrated.     Buckram,  $1.75   net- 

This  volume  is  designed  for  the  obstetric  and  gynecologic  nurse.  Obstetric 
nursing  demands  some  knowledge  of  natural  pregnancy  and  of  the  signs  of 
accidents  and  diseases  which  may  occur  during  pregnancy.  It  also  requires 
knowledge  and  experience  in  the  care  of  the  patient  and  child.  Gynecologic 
nursing  is  really  a  branch  of  surgical  nursing,  and  as  such  requires  special 
instruction  and  training.  This  volume  presents  this  information  in  the  most  con- 
venient form. 

The  Lancet,  London 

"  Not  only  nurses,  but  even  newlv  qualified  medical  men.  would  learn  a  great  deal  by  a 
perusal  of  this  book.  It  is  written  in  a  clear  and  pleasant  style,  and  is  a  work  we  can  recom- 
mend." 


GYNECOLOGY  AXD    OBSTETRICS. 


Schaffer  and  Edgar's 

Labor  and  Operative  Obstetrics 

Atlas  and  Epitome  of  Labor  and  Operative  Obstetrics.     By  Dr. 

O.  Schaffer,  of  Heidelberg.  From  the  Fifth  Revised  and  Enlarged 
German  Edition.  Edited,  with  additions,  by  J.  Clifton  Edgar,  M.  D., 
Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University  Medi- 
cal School,  New  York.  With  1.4  lithographic  plates  in  colors,  139  other 
illustrations,  and  ill  pages  of  text.  Cloth,  $2.00  net.  In  Saunders' 
Hand-Atlas  Series. 

This  book  presents  the  act  of  parturition  and  the  various  obstetric  operations 
in  a  series  of  easily  understood  illustrations,  accompanied  by  a  text  treating  the 
subject  from  a  practical  standpoint.  The  author  has  added  many  accurate  repre- 
sentations of  manipulations  and  conditions  never  before  clearly  illustrated. 

American  Medicine 

"  The  method  of  presenting  obstetric  operations  is  admirable.  The  drawings,  representing 
original  work,  have  the  commendable  merit  of  illustrating  instead  of  confusing.  It  would  be 
difficult  to  find  one  hundred  pages  in  better  form  or  containing  more  practical  points  for 
students  or  practitioners." 

Schaffer  and  Edgar's 

Obstetric  Diagnosis  and  Treatment 

Atlas  and  Epitome  of  Obstetric  Diagnosis  and  Treatment.     By 

Dr.  O.  Schaffer,  of  Heidelberg.  From  the  Second  Revised  German 
Edition.  Edited,  with  additions,  by  J.  Clifton  Edgar,  M.  D.,  Professor 
of  Obstetrics  and  Clinical  Midwifery,  Cornell  University  Medical  School, 
N.  Y.  With  122  colored  figures  on  56  plates,  38  text-cuts,  and  315 
pages  of  text.     Cloth,  $3.00  net.     In  Saunders'  Hand-Atlas  Series. 

This  book  treats  particularly  of  obstetric  operations,  and,  besides  the  wealth 
of  beautiful  lithographic  illustrations,  contains  an  extensive  text  of  great  value. 
This  text  deals  with  the  practical,  clinical  side  of  the  subject.  The  symptoma- 
tology and  diagnosis  are  discussed  with  all  necessary  fullness,  and  the  indications 
for  treatment  are  definite  and  complete. 

New  York  Medical  Journal 

"The  illustrations  are  admirably  executed,  as  they  are  in  all  of  these  atlases,  and  the  text 
can  safely  be  commended,  not  only  as  elucidatory  of  the  plates,  but  as  expounding  the  scien- 
tific midwifery  of  to-day." 


SAUNDERS'    BOOKS   ON 


Galbraith's 
Four  Epochs  of  Woman's  Life 

The  Four  Epochs  of  Woman's  Life :  A  Study  in  Hygiene.  By 
Anna  M.  Galbraith,  M.  D.,  author  of  "  Hygiene  and  Physical  Cul- 
ture for  Women"  ;  Fellow  of  the  New  York  Academy  of  Medicine,  etc. 
With  an  Introductory  Note  by  John  H.  Musser,  M.  D.,  Professor  of 
Clinical  Medicine,  University  of  Pennsylvania  i2mo  volume  of  200 
pages.     Cloth,  $1.25  net. 

MAIDENHOOD,  MARRIAGE.  MATERNITY,  MENOPAUSE 

In  this  instructive  work  are  stated,  in  a  modest,  pleasing,  and  conclusive  manner, 
those  truths  of  which  every  woman  should  have  a  thorough  knowledge.  Written, 
as  it  is,  for  the  laity,  the  subject  is  discussed  in  language  readily  grasped  even  by 
those  most  unfamiliar  with  medical  subjects. 

Birmingham  Medical  Review,  England 

"  We  do  not  as  a  rule  care  for  medical  books  written  for  the  instruction  of  the  public.  But 
we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  is  in  the  main  wise  and  wholesome." 

American  Year-Book 

Saunders'   American  Year=Book  of  Medicine  and   Surgery.     A 

Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
Branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  foreign  authors  and  inves- 
tigators. Arranged,  with  critical  editorial  comments,  by  eminent  Ameri- 
can specialists,  under  the  editorial  charge  of  George  M.  Gould,  A.M., 
M.  D.  In  two  volumes  :  Vol.  I. —  General  Medicine,  octavo,  715  pages, 
illustrated;  Vol.  II. —  General  Surgery,  octavo,  684  pages,  illustrated. 
Per  vol.:  Cloth,  $3.00  net;  Half  Morocco,  $3.75  net.  Sold  by  Sub- 
scription. 

EQUIVALENT  TO   A   POST-GRADUATE   COURSE 

The  contents  of  these  volumes  is  much  more  than  a  compilation  of  data.  The 
extracts  are  carefully  edited  and  commented  upon  by  eminent  specialists,  the 
reader  thus  obtaining  also  the  invaluable  annotations  and  criticisms  of  the  editors, 
all  leaders  in  their  several  specialties.      The  Year- Book  is  amply  illustrated. 

The  Lancet,  London 

"  It  is  much  more  than  a  mere  compilation  of  abstracts,  for,  as  each  section  is  entrusted  to 
experienced  and  able  contributors,  the  reader  has  the  advantage  of  certain  critical  commen- 
taries and  expositions  .  .  .  proceeding  from  writers  fully  qualified  to  perform  these  tasks." 


GYNECOLOGY  AND    OBSTETRICS. 


Schaffer  and  Norris* 
Gynecology 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  0.  Schaffer,  of 
Heidelberg.  From  the  Second  Revised  and  Enlarged  German  Edition. 
Edited,  with  additions,  by  Richard  C.  Norris,  A.  M.,  M.  D.,  Gynecolo- 
gist to  Methodist  Episcopal  and  Philadelphia  Hospitals.  With  207 
colored  figures  on  90  plates,  65  text-cuts,  and  308  pages  of  text. 
Cloth,  $3.50  net.     In  Saunders'  Hand-Atlas  Series. 

The  value  of  this  atlas  to  the  medical  student  and  to  the  general  practitioner 
will  be  found  not  only  in  the  concise  explanatory  text^  but  especially  in  the  illus- 
trations. The  large  number  of  colored  plates,  reproducing  the  appearance  of 
fresh  specimens,  give  an  accurate  mental  picture  and  a  knowledge  of  the  changes 
induced  by  disease  of  the  pelvic  organs  that  cannot  be  obtained  from  mere 
description. 

American  Journal  of  the  Medical  Sciences 

"  Of  the  illustrations  it  is  difficult  to  speak  in  too  high  terms  of  approval.  They  are  so 
clear  and  true  to  nature  that  the  accompanying  explanations  are  almost  superfluous.  We 
commend  it  most  earnestly." 

Hirst's  Diseases  of  Women 


A  Text-Book  of  Diseases  of  Women.  By  Barton  Cooke  Hirst, 
M.  D.,  Professor  of  Obstetrics  in  the  University  of  Pennsylvania. 
Handsome  octavo  volume  of  about  800  pages,  magnificently  illus- 
trated.     In  Preparation. 

This  new  work  of  Dr.  Hirst's  will  be  on  the  same  lines  as  his  Text-Book  of 
Obstetrics.  The  wealth  of  illustrations  will  be  entirely  original  from  photographs 
and  water-colors  made  especially  for  this  work. 

Webster's  Obstetrics 

A  Text=Book  of   Obstetrics.     By  J.  Clarence  Webster,  M.  D., 

F.  R.  C.  P.  E.,  Professor  of  Obstetrics  and  Gynecology,  Rush  Medical 
College,  in  affiliation  with  the  University  of  Chicago,  etc.  Handsome 
octavo  volume  of  900  pages,  finely  illustrated.     In  Preparation. 

This  is  an  entirely  new  work  by  an  eminent  teacher  of  wide  experience. 
The  book  will  be  thoroughly  practical  and  the  text  magnificently  illustrated. 


SAUNDERS'    BOOKS    ON 


American  Pocket  Dictionary  Third  Revised  Edition 

The  American  Pocket  Medical  Dictionary.  Edited  by  W. 
A.  Newman  Dorland,  A.M.,  M.  D.,  Assistant  Obstetrician  to  the 
Hospital  of  the  University  of  Pennsylvania ;  Fellow  of  the  American 
Academy  of  Medicine.  Over  500  pages.  Full  leather,  limp,  with 
gold  edges.     $1.00  net ;  with  patent  thumb  index,  $1.25  net. 

James  W.  Holland,  M.  D.. 

Professor  of  Medical  Chemistry  and  Toxicology,  and  Dean,  Jefferson  Medical  College, 

Philadelphia. 
"  I  am  struck  at  once  with  admiration  at  the   compact  size  and  attractive   exterior.     I 
nend  it  to  our  students  without  reserve." 


Long's  Syllabus  of  Gynecology 

A  Syllabus  of  Gynecology,  arranged  in  conformity  with 
"American  Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D., 
Emeritus  Professor  of  Diseases  of  Women  and  Children,  Medical 
College  of  Virginia,  etc.     Cloth,  interleaved,  #1.00  net. 

Brooklyn  Medical  Journal 

"  The  book  is  certainly  an  admirable  resume  of  what  every  gynecological  student  and 
practitioner  should  know,  and  will  prove  of  value." 

Cragin's    Gynecology.  Fifth  Revised  Edition 

Essentials  of  Gynecology.  By  Edwin  B.  Cragin,  M.  D., 
Professor  of  Obstetrics,  College  of  Physicians  and  Surgeons,  New 
York.  Crown  octavo,  200  pages,  62  illustrations.  Cloth,  $1.00 
net.     In  Saunders'   Question-  Compend  Series. 

The  Medical  Record,  New  York 

"A  handy  volume  and  a  distinct  improvement  on  students'  compends  in  general. 
No  author  who  was  not  himself  a  practical  gynecologist  could  have  consulted  the 
student's  needs  so  thoroughly  as  Dr.  Cragin  has  done." 

Boisliniere's   Obstetric   Accidents,   Emergencies,   and 
Operations 

Obstetric  Accidents,  Emergencies,  and  Operations.  By 
the  late  L.  Ch.  Boisliniere,  M.  D.,  Emeritus  Professor  of  Ob- 
stetrics, St.  Louis  Medical  College  ;  Consulting  Physician,  St.  Louis 
Female  Hospital.     381  pages,  illustrated.     Cloth,  $2.00  net. 

British  Medical  Journal 

"  It  is  clearly  and  concisely  written,  and  is  evidently  the  work  of  a  teacher  and  practi- 
tioner of  large  experience,    its  merit  lies  in  the  judgment  which  comes  from  experience." 

AshtOn's    Obstetrics.  Fifth  Edition,  Revised  and  Enlarged 

Essentials  of  Obstetrics.  By  W.  Easterly  Ashton,  M.  D., 
Professor  of  Gynecology  in  the  Medico-Chirurgical  College,  Phila- 
delphia. Crown  octavo,  252  pages,  75  illustrations.  Cloth,  $1.00 
net.     In  Saunders'  Question- Compend  Series. 

Southern  Practitioner 

"An  excellent  little  volume  containing  correct  and  practical  knowledge.  An  admir- 
able compend,  and  the  best  condensation  we  have  seen." 


COLUMBIA   UNIVERSITY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
-"h-ation  of  a  definite  period  after  the  date  of  borrowing, 
by  "  e  rules  of  the  Library     r  by  spe^ 
*:  -arian  in  char 


